Council of Governors Meeting 11 August · Council of Governors Meeting There will be a meeting of the COUNCIL OF GOVERNORS of West Suffolk NHS Foundation Trust on Tuesday, 11 August

COUNCIL OF GOVERNORS MEETINGTuesday 11 August 2020, 18.00, viaMicrosoft Teams

Council of Governors Meeting Page 1 of 103

AGENDA


Council of Governors Meeting

There will be a meeting of the COUNCIL OF GOVERNORS of West Suffolk NHS Foundation Trust on Tuesday, 11 August 2020 at 18.00 via Microsoft Teams.

Sheila Childerhouse, Chair

Agenda

General duties/Statutory role

(a) To hold the Non-Executive Directors individually and collectively to account for

the performance of the Board of Directors. (b) To represent the interests of the members of the corporation as a whole and

the interests of the public.

The Council’s focus in holding the Board to account is on strategy, control, accountability and culture.

18.00 GENERAL BUSINESS

1. Public meeting The Council of Governors is invited to note the following: “That representatives of the press, and other members of the public, are excluded from the meeting having regard to the guidance from the Government regarding public gatherings.”

Sheila Childerhouse

2. Apologies for absence To receive any apologies for the meeting.

Sheila Childerhouse

3. Welcome and introductions To welcome David Wilkes to the meeting and request mobile phones be switched to silent.

Sheila Childerhouse

4. Declaration of interests for items on the agenda To receive any declarations of interest for items on the agenda

Sheila Childerhouse

5. Minutes of the previous meeting (enclosed) To note the minutes of the meeting held on 6 May 2020

Sheila Childerhouse

6. Matters arising action sheet (enclosed) To note updates on actions not covered elsewhere on the agenda

Sheila Childerhouse

7. Chair’s report (enclosed) To receive an update from the Chair

Sheila Childerhouse

8. Chief executive’s report (enclosed) To note a report on operational and strategic matters

Craig Black

9. Governor issues (enclosed) To note the issues raised and receive any agenda items from Governors for future meetings

Liz Steele

18.20 DELIVER FOR TODAY

10. COVID report (enclosed) To note the summary report

Richard Davies


11. Quality and performance report (enclosed) To note the report

Angus Eaton

12. Summary finance & workforce report (enclosed) To note the summary report

Alan Rose

18.50 INVEST IN QUALITY, STAFF AND CLINICAL LEADERSHIP

13. New NED introduction (verbal) To receive an introductory presentation

David Wilkes

14. Trust improvement plan (enclosed) To note the report

Sheila Childerhouse

19.20 BUILD A JOINED-UP FUTURE

15. Pathology services (enclosed) To receive an update

Louisa Pepper

16. Annual Report & Accounts 2019/20 (on Trust website or hard copy on request) To receive the Annual Report & Accounts for 2019/20 https://www.wsh.nhs.uk/Corporate-information/Information-we-publish/Annual-reports.aspx

Richard Jones

17. Annual Audit Letter (enclosed) To receive the report from BDO, External Auditors

Matthew Weller, BDO

19.45 GOVERNANCE

18. Report on constitutional changes (enclosed) To note the report.

Richard Jones

19. Report from Nominations Committee (enclosed) To note a report from the Nominations Committee meeting of 25 June 2020

Sheila Childerhouse

20. Report from Engagement Committee (enclosed) To receive the minutes from the meeting of 21 July 2020

Florence Bevan

21. Lead Governor report (enclosed) To receive a report from the Lead Governor

Liz Steele

22. Staff Governors report (verbal) To receive a report from the Staff Governors

Peta Cook

23. Annual external audit review (enclosed) To receive a report and recommendation from the Audit Committee on the Trust’s External Auditors BDO

Angus Eaton

20.00 ITEMS FOR INFORMATION

24. Dates for meetings for 2020: Tuesday 22 September – AMM (plan to hold using MS Teams) Wednesday 11 November

Sheila Childerhouse

25. Reflections on meeting To consider whether the right balance has been achieved in terms of information received and questions for assurance and the Trust’s values and behaviours observed.

Sheila Childerhouse

20.05 CLOSE Council of Governors Meeting Page 4 of 103

https://www.wsh.nhs.uk/Corporate-information/Information-we-publish/Annual-reports.aspx


1. Public meetingThe Council of Governors is invited tonote the following:“That representatives of the press, andother members of the public, are excludedfrom the meeting having regard to theguidance from the Government regardingpublic gatherings.”For ReferencePresented by Sheila Childerhouse


2. Apologies for absenceTo receive any apologies for the meeting.For ReferencePresented by Sheila Childerhouse


3. Welcome and introductionsTo welcome David Wilkes to the meetingand request mobile phones be switched tosilent.For ReferencePresented by Sheila Childerhouse


4. Declaration of interests for items on theagendaTo receive any declarations of interest foritems on the agendaFor ReferencePresented by Sheila Childerhouse


5. Minutes of the previous meeting(enclosed)To approve the minutes of the meetingheld on 6 May 2020For ApprovalPresented by Sheila Childerhouse


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DRAFT

MINUTES OF THE COUNCIL OF GOVERNORS’ MEETING HELD ON WEDNESDAY 6 MAY 2020 AT 17.30pm

Via Microsoft Teams

COMMITTEE MEMBERS Attendance Apologies

Sheila Childerhouse Chair

Peter Alder Public Governor

Mary Allan Public Governor

Florence Bevan Public Governor

June Carpenter Public Governor

Peta Cook Staff Governor

Justine Corney Public Governor

Judy Cory Partner Governor

Jayne Gilbert Public Governor

Mark Gurnell Partner Governor

Andrew Hassan Partner Governor

Rebecca Hopfensperger Partner Governor

Robin Howe Public Governor

Javed Imam Staff Governor

Amanda Keighley Staff Governor

Gordon McKay Public Governor

Sara Mildmay-White Partner Governor

Laraine Moody Partner Governor

Barry Moult Public Governor

Jayne Neal Public Governor

Adrian Osborne Public Governor

Joe Pajak Public Governor

Vinod Shenoy Staff Governor

Jane Skinner Public Governor

Liz Steele Public Governor

Martin Wood Staff Governor

In attendance Helen Beck Chief Operating Officer

Richard Davies Non-Executive Director

Stephen Dunn Chief Executive

Angus Eaton Non-Executive Director

Georgina Holmes FT Office Manager (minutes)

Richard Jones Trust Secretary & Head of Governance

Gary Norgate Non-Executive Director

Louisa Pepper Non-Executive Director

Rowan Procter Executive Director of Nursing

Alan Rose Non-Executive Director

Action GENERAL BUSINESS

20/23 PUBLIC MEETING The Council of Governors noted that representatives of the press, and other members of the public, were excluded from the meeting having regard to the guidance from the Government regarding public gatherings.

20/24 APOLOGIES Apologies for absence were noted as above.


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20/25 WELCOME AND INTRODUCTIONS The Chair welcomed everyone to the meeting and explained that the Trust’s constitution did not account for governors meeting virtually; therefore, it would not be possible to make any decisions at this meeting. An agenda item proposing changes to the constitution would be discussed later in the meeting.

20/26 DECLARATIONS OF INTEREST

There were no declarations of interest relating to items on the agenda.

20/27 MINUTES OF THE COUNCIL OF GOVERNORS MEETING HELD ON 11 FEBRUARY 2020 The minutes of the meeting held on 11 February 2020 were approved as a true and accurate record subject to the following amendment: Page 9, 20/15; include reference to Glemsford surgery and pharmacy.

It was explained that WSFT now owned the Glemsford practice and would be looking at this as a model for similar development of integration across the system.

20/28 MATTERS ARISING ACTION SHEET The ongoing actions were reviewed and the following noted:

Item 188; review how patients with no fixed address are identified to the housing department prior to discharge. This was an area that had been impacted by COVID; the national response was to move these people off the streets and into hotel type accommodation. Currently 80 more people than normal were being accommodated and seeing to their health needs had become quite a challenge. There had been a real commitment from health, housing and the county council to try and make improvements in this area. Sara Mildmay-White had spent a very useful day with the discharge team and a member of the county council housing team was now working with WSFT’s team. The situation had changed due to COVID and the teams were working together but were missing the support of mental health and drug and alcohol services.

The completed actions were reviewed and there were no issues.

20/29 CHAIR’S REPORT

The Chair paid tribute to staff across the whole organisation for all their work to prepare for COVID, and their willingness to work in a different way and often in different roles. Excellent transformation in a number of areas had been achieved which otherwise would have taken months or years to achieve.

She also paid tribute to the system, eg social care and the voluntary sector. The Integrated Care System (ICS) was starting to look at what was working well across the three Alliances and what could be learned from and taken forward into the next phase moving to the new normal.

An update was given on the NED recruitment process for which there were a number of strong potential candidates.

20/30 CHIEF EXECUTIVE’S REPORT

The Chief Executive referred to the excellent work of staff, the system and support networks who had come together to focus on COVID.


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To date there had been 44 COVID related deaths at WSFT and he passed on the Trust’s sympathies to the families affected by this. Whilst UK had one of the highest death rates in Europe the NHS had coped very well compared to some other countries.

There had been 69 successful discharges from WSFT. There and been a massive change in the way that primary care, the local and county council were working together which had had a big effect on discharging patients into the community.

The reports to the board and Council of Governors had changed as a result of COVID as it was currently not appropriate to track the performance of some indicators eg A&E performance.

The Trust had delivered its financial plan for last year and over delivered its cost improvement programme (CIP) by over £200k, the majority of which was recurring. All COVID related costs for the last financial year would be reimbursed but there was some uncertainty about whether this would be the case for the current year.

Governors had previously been briefed on the structural challenges and there had been some issues in the area where theatres were located. The estates team had addressed this but this had presented some challenges in developing the expansion of the critical care unit (CCU) and other areas had been relocated to manage this.

Despite the focus on COVID work continued on the plan for a new hospital. A joint workshop had been arranged for the board and governors to discuss the operational plan and consider the strategic outline case (SOC) for the new hospital, but unfortunately this had been unable to take place. The development of the outline business case (OBC) would be discussed today in the closed board meeting, due to the confidential information it contained. The next step would be sign up by the system and then it was hoped there could be a briefing to governors on the SOC. The development of the OBC would require public engagement which would involve input/assistance from governors.

Action: arrange update for governors on development of new hospital.

R Jones

Q

A

Would the design of the new hospital take into account the need to manage a similar situation to COVID? There was a need to understand what the post-COVID world would look like in terms of healthcare. The issues that were being faced would be taken into account for when/if a similar situation occurred in the future.

Q

A

NHSEI would be recommending that every member of staff had a risk assessment to ensure that they were safe. Also, BAME staff were thought to be at greater risk, therefore every organisation should have a BAME leader who was overseeing this. What was WSFT doing about this? WSFT had been through the process of asking all staff to complete risk assessments. With regard to BAME staff the Trust was adhering to the guidance that was being issuing around this.

Q

A

What was the timescale for completion of the new hospital? This was very difficult to predict, but considering the structural issues with the current building this needed to be progressed as soon as possible. However, due to COVID it was not known what the economic situation would be. Currently it was hoped to submit the full business case by September 2023 with construction commencing late 2023. This could take five to seven years, depending on the issues that would need to be addressed once approval was received.


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DELIVER FOR TODAY

20/31 COVID REPORT

COVID had been the main focus for the Trust over the past few months. A virtual staff briefing would be taking place tomorrow and this presentation would then be put onto the Trust’s intranet.

There had been a huge amount of digital change to enable a large number of staff to work from home in order to support social distancing, eg Miscrosoft Teams and Visionable which enabled virtual outpatient consultations.

The Trust was aware that staff who were shielding could feel very isolated and was keeping in touch with them.

In order to protect staff all patients would be treated as if they have or might have COVID. All patients would be swabbed and staff would continue to wear appropriate levels of PPE for the patients they were treating.

In order to protect patients on the wards only four beds in a bay were being used unless there was a group of patients with confirmed COVID in which case all six beds in a bay would be used.

The emergency department (ED) and radiology had a separate area for anyone who was exhibiting COVID symptoms.

The patient experience team were helping patients to keep in touch with relatives by using iPads to video call. Clinicians were also assisting to mitigate for the fact that relatives were unable to visit.

Critical care capacity had been expanded from 9 to 19 beds with further plans to increase to 27 beds if required. This had had the biggest impact on the Trust’s ability to do elective work as anaesthetists and the critical care team were required to manage these beds.

The number of beds in the community had also been increased, including 14 additional beds at Newmarket hospital. A lot of work had been undertaken to support the community teams and enhance their skills so that patients requiring a higher level of care could be moved into community beds. Discussions were also taking place with Mareham Park about additional beds; beds for discharged patients had already been purchased which gave additional care home capacity and were being supported by staff from WSFT.

The Trust was now starting to see an increase in ED attendances and admissions, although these were still below pre-COVID levels. However, it was unlikely to be able to respond to previous levels of demand as everything would take longer and this would be a real challenge for staff and capacity. Both WSFT and the CCG were using the media to encourage people to use this service appropriately.

There did not appear to be a significant issue with people not attending the hospital for appointments. Those who did not wish to attend had been clinically reviewed and were being seen virtually or by telephone, and were recorded as not wishing to be seen at this time. Patients on cancer pathways etc were being kept in touch with. The main concern was that people were not visiting their GPs if they had symptoms.

Regular discussions and meetings took place about PPE and a lot of work had been done across the organisation to manage supplies. To date the Trust had not been in the position of not having sufficient PPE of the appropriate type required in accordance with Public Health England and national guidance. There was a global shortage of some items and the Trust had had discussions with the unions about a number of ‘what ifs’ a shortage did occur. Throughout the past few months the Trust had been planning for the worst but hoping for the best. WSFT had been in a better position than a lot of organisations and this remained an ongoing focus.


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Q

A

There may be a higher demand for PPE in community paediatrics when schools went back and staff were required to go into schools; had this been taken into account? It was recognised that this and an increase in elective activity would result in a requirement for more PPE therefore this was being factored into the planning.

Modelling undertaken by Dr Helena Jopling suggested that WSFT had not yet

reached its peak and to date the number of cases WSFT had been seeing had been following her trend analysis. The modelling showed a peak towards the end of May and then a drop and peak again June through to July. If the number of cases continued to increase Addenbrookes, Papworth and Norfolk & Norwich were being established as local Nightingale hospitals and would support WSFT so that patients could be transferred to one of these.

New management structures had been established to run the organisation at this time, ie Strategic Group. The Core Resilience Team which was in place at all times for emergency planning and had been enhanced during the COVID crisis to look at future planning and what resources would be required. The Tactical group responded to the day to day issues. There was a senior management presence on site seven days a week, 8.00am to 8.00pm with plans in place for 24/7 cover if required.

Recovery would be the new normal; there were likely to be fluctuating peaks in COVID demand which might require the Trust to periodically increase and then decrease its normal workload. Plans had been submitted today as to how WSFT would bring the two week wait cancer activity up to full speed; as referrals increased activity would have to increase. The national guidance on endoscopy had changed to allow an increase activity, with routine endoscopies starting again next week.

The second phase of the new normal would be too look at all other activity. However, there would be a large number of constraints around this as everything would take much longer with staff wearing PPE. There would also be issues with resources, beds, money etc and this was being factored into the plan as to what the new normal would look like.

A lot of support had been put in place for staff, including free car parking, accommodation where required, psychiatric support etc.

Community teams were working alongside care home where possible and testing for staff and residents was now taking place. West Suffolk was in a better positon than east Suffolk due to the positive relationships that were already in place. The national plan had been very pro-active in preparing for the worst in hospitals but regretfully this had not been the same for care homes.

A daily call took place between the community team, social services and the care home teams. There was a list of care homes with RAG (red, amber, green) rating and those rated as red were helped and supported as required. There was a big testing initiative in care homes but there was an issue with getting information across boundaries. Although care homes had initially been left behind in the preparations the situation had improved greatly and west Suffolk was ahead of many areas and Suffolk County Council was very supportive of the care homes. There were no reports of care homes running out of PPE.

Differing percentages of false negatives for testing were being reported. This was partly due to issues with swabbing techniques and there was growing evidence around the timing of when swabs were taken following the onset of symptoms, however this was the currently best available test until an antibody test had been developed which would be a better option.


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Q

A

What was happening about staff testing; there was a concern about the distance they had to travel to a testing centre? Staff could choose from a number of options where they were tested, eg Colchester or Stansted, but the closest was in the ED car park which was managed via and booking system.

20/32 SUMMARY FINANCE & WORKFORCE REPORT

At the Council of Governors meeting last August it was not clear as to whether the financial target for the year would be achieved. At the time the overspend was attributed to temporary staff and extra sessions due to additional activity. In response to this the finance team had negotiated with the CCG and an additional payment for the activity had been received.

The CIP had been challenging but £9.1m of savings had been delivered, ie over £200k more than the plan. Many of these savings were recurring which was potentially good for 2020/21.

The financial recovery plan (FIP) to achieve an additional £1.8m of savings had not been achieved but came in at £1.6m. However, as the Trust had achieved its financial target it should receive all provider sustainability fund (PSF) payments associated with this.

The cash position was currently good at £2.4m and this was monitored on a daily basis.

There had been an increase in spend on temporary staff which was due to COVID activity and also a relaxation around controls. The NEDs would be keeping an eye on this moving forward.

Details of the capital programme were given in the report. It was noted that the emergency department was progressing toward the full business case (FBC).

INVEST IN QUALITY, STAFF AND CLINICAL LEADERSHIP

20/33 TRUST IMPROVEMENT REPORT

The CQC report had identified 74 items that needed to be addressed; 32 of which were must do and 42 should do.

Following the quality summit in March which was attended by all key stakeholders WSFT had developed an action plan. An action log had also been produced to show how each item would be implemented and monitored.

A number of items had been paused due to COVID, however others continued to be addressed. The progress of these would be reviewed regularly by the board and there would also be a periodic review of the actions that had been paused; the next would be in July.

There was also ongoing oversight and feedback from the CCG and a summary of this would continue to be reported at Council of Governors meetings.

Action: provide update on Trust improvement plan to CoG meetings.

It was important not to lose focus on quality of care during COVID and the NEDs would continue to challenge on this, whilst recognising that this was a difficult situation. Currently they felt assured that things were not getting lost, even those actions that were being paused. Work was being undertaken to look at how to monitor quality in the current COVID situation and moving forwards.

Complaints were unable to be investigated in the normal way but the NEDs were assured that they would be looked at eventually. In the meantime, work was ongoing to ensure that any themes or trends were identified and addressed in a timely manner.

H Beck


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Q

A

What about the considerable number of items that had been partially paused; particularly maternity checks on resuscitation equipment? The actions that were considered to be important had been fully implemented and would be followed up with weekly audits to provide assurance that this was the case and they were being embedded.

Q

A

Had there been any indication from the CQC as to when they might want to come back in or have any verification of these actions? The governors would like more information on why the NEDs were assured about this; it would be helpful if this could be clarified. Decisions about the action plan and delays to actions had not been made in isolation and were being overseen by the CCG, and the CQC was being kept updated on this. The CQC had suspended normal regulatory inspections but there had been some suggestion that in the next few weeks they could start to give some indication of what the programme would look like going forwards. Therefore, it should be assumed that the CQC would want to come back in to test some of these actions.

BUILD A JOINED UP FUTURE

20/34 PATHOLOGY SERVICES

Last Monday ESNEFT had informed WSFT of their wish to end the network pathology arrangement, ie NEESPS. This had come as a surprise to both WSFT and the regional team, and the reasons for this were not clear.

A lot of work was already going on to consider the next steps. A number of briefings had taken place with WSFT staff who appeared to be very positive about this.

Craig Black would be working on the separation and negotiating with ESNEFT.

It was hoped that this would make WSFT more attractive as an employer and it would also be able to choose who it partnered with around some aspects of pathology, possibly Addenbrooke’s or Norfolk & Norwich.

This would be discussed in more detail by the scrutiny committee and regular updates would be provided to the board and to governor meetings.

Action: Provide update on pathology services to governor meetings.

N Jenkins

Q

A

What would the financial impact of this be? Significant investment would have been required in pathology whether or not WSFT remained in a networked arrangement with ESNEFT. However, WSFT would now have more control over this but careful negotiation was required with ESNEFT. WSFT saw this as an opportunity not a threat.

GOVERNANCE

20/35 PROPOSED CHANGES TO THE CONSTITUTION

The Council of Governors needed to be in a position during this period to enable it to convene and make decisions virtually; currently the Trust’s constitution did not allow for this.

This paper set out the proposed process to make reasonable changes to the constitution which would allow the Council of Governors to make decisions. It was proposed that there should be a post or email ballot for governors, followed by a recommendation to the board. It was hoped that by the end of this month this would enable a new way of working.


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The Council of Governors agreed that this proposal should be progressed.

Action: progress proposal to amend constitution as set out in this paper

R Jones

20/36

REPORT FROM ENGAGEMENT COMMITTEE

The current COVID situation meant that it was very difficult for governors to undertake their engagement role.

As a result, it was proposed to develop digital communication and it was likely that more of this type of engagement would continue in the future.

The engagement committee would continue to review technology for interaction not only with governors but also the public.

The Council of Governors noted the amendments to the Membership Strategy and terms of reference for the engagement committee, both of which reflected the need to develop digital communication.

20/37 LEAD GOVERNOR REPORT

Liz Steele, on behalf of the governors, thanked the executive team and staff across the organisation for all their work during this difficult time.

20/38 STAFF GOVERNORS REPORT

It was explained that the new normal would mean that the ability of both the hospital and community services to deliver services would not be the same as previously and this needed to be communicated to the public.

The move to a new normal would be a challenge and it was not yet fully understood what this would be. However, the COVID situation had enabled staff to look at innovations and implement these more quickly than would have been done otherwise.

This had also been the case in primary care where transformation in some areas had been marked and rapid.

ITEMS FOR INFORMATION

20/39 DATES FOR COUNCIL OF GOVERNOR MEETINGS FOR 2020 Tuesday 11 August Tuesday 22 September - Annual members meeting (under review) Wednesday 11 November

20/40 REFLECTIONS ON MEETING

A positive meeting, with good use of the chat facility.

20/41 ANY OTHER BUSINESS

The Chair thanked the NEDs, particularly Louisa Pepper, for chairing the ethics group and also Angus Eaton for his input into this group as a member. She was very grateful to them all for supporting the executive team and their engagement in what was happening in the Trust.

Rowan Procter would be leaving WSFT at the end of the month and the Chair paid tribute to her for everything she had done for the Trust.


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This was Gary Norgate’s last meeting of the Council of Governors; he would be moving into a new role supporting the development of the new hospital. He would be greatly missed as a NED and had been very supportive whilst also challenging when necessary.

Gary Norgate said that he was sorry to be leaving his role as NED; he had enjoyed working with the governors and thanked them all for their support.


6. Matters arising action sheet (enclosed)To note updates on actions not coveredelsewhere on the agendaFor ReferencePresented by Sheila Childerhouse


REPORT TO: Council of Governors

MEETING DATE: 11 August 2020

SUBJECT: Matters Arising Action Sheet from Council of Governors Meeting of 6 May 2020

AGENDA ITEM: 6

PRESENTED BY: Sheila Childerhouse, Chair

FOR: Information

The attached details action agreed at previous Council of Governor meetings and includes ongoing and completed action points with a narrative description of the action taken and/or future plans as appropriate.

Verbal updates will be provided for ongoing action as required.

Where an action is reported as complete the action is assessed by the lead as finished and will be removed from future reports.


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Ongoing action points

Ref. Date of Meeting

Item Action Action taken Lead Target date

RAG rating for delivery

193 11/02/20 Closed meeting

20/05 Arrange for Governwell to give a joint training session for NEDs and governors

Spoken with NHS Providers example programme appended (Appendix B). To be scheduled when social distancing restrictions are lifted, now likely to be after elections. Option to delivery as part of the refresh training early 20201 with newly elected Governors. Request to approve revised timescale

S Childerhouse

/ R Jones 31/07/20

Feb 2021

Red

194 11/02/20 20/08 item 1

An update on the review of the HR policy framework to be provided to a future meeting.

Included as part of CQC action plan – and being progress through the workforce workstream. A fuller report to be provided at the November meeting. Request to approve revised timescale

J Over 6/5/20 11/11/20

Red

195 11/02/20 20/08 item 2

Further detail on ward accreditation to be provided to a future meeting.

Ward accreditation programme (as per NHSI) will be supported by a review of nursing quality metrics (including but not limited to Safety thermometer) including data distribution, display and data sharing, use in improvement not just performance and reporting via IQPR and other pathways is planned, led by heads of nursing and supported by Governance. this will link into the ongoing wider review of the IQPR led by the Performance team. The new Chief Nurse and Deputy Chief Nurse are working their way through our current state and developing a vision of how we will deliver a ward accreditation programme. The pandemic has clearly had an impact on the progression. An extension on this action has been requested and a progress update will be provided at the November meeting. Request to approve revised timescale

S Wilkinson 6/05/20 Feb 2021

Red`


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20/08 David Wilkes and Rosemary Mason (subject to approval of her appointment) to be asked to present to a Council of Governors meeting.

David Wilkes invited to present to CoG meeting on 11 August 2020. Rosemary Mason to be asked to present to meeting on 11 November 2020

R Jones 11/11/20 Green

207 07/07/20 20/08 Review terms of reference for Nominations Committee following governor elections.

To be actioned through the Nominations Committee (including input from Governors after elections)

R Jones May 2021

Green

See separate sheet for completed action points


Completed action points




188 06/08/19

19/47

Review how patients with no fixed address are identified to the housing department prior to discharge.

A meeting has recently taken place with the council re WSFT’s duty to refer. WSFT has also appointed (on a one-year contract) a health and housing officer who will start as soon as the funding is transferred from the CCG. They will pick up patients in ED and the base wards and liaise directly with the housing department. The CCG funding will also pay for a one bedroom flat in the centre of Bury St Edmunds for patients who require temporary accommodation. Sara Mildmay-White was invited to shadow the discharge team to provide her with assurance that a process is in place. She reported that she had spent a very useful day on 19/02/20 with the discharge team and a member of the county council housing team was now working with WSFT’s team. The situation had changed due to COVID and the teams were working together but were missing the support of mental health and drug and alcohol services.

N Jenkins / R Jones S Mildmay-White / G Holmes

19/02/20

Closed

201 06/05/20 20/30 Arrange update for governors on development of new hospital

Briefing provided as part of closed agenda to include discussion of future communication plan for the programme.

R Jones 11/08/20 Closed


20/08 Board to be asked to approve the appointment of Rosemary Mason, taking into account the requirement for a future recruitment process, value for money and how this would fit alongside the responsibilities of the Non-Executive Directors.

Recommendation approved at the Trust Board meeting on 31 July 2020 – appointment as an Associate NED for two year term.


202 06/05/20 20/33 Provide update on Trust improvement plan to CoG meetings.

Agenda item for CoG meeting of 11 August H Beck 11/08/20 Closed


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203 06/05/20 20/34 Provide update on pathology services to governor meetings.

Agenda item for CoG meeting of 11 August N Jenkins 11/08/20 Closed

204 06/05/20 20/35 Progress proposal to amend constitution

The proposed had been unanimously supported by governors and the board approved the amendments to the Trust Constitution on 29 May 2020. The Constitution has been updated to reflect the agreed changes. Agenda item for CoG meeting of 11 August.



Annex A – ongoing issues log The Governors are asked to:

1. Note the updates to ongoing issues 2. Consider whether any other items from the action list should be considered for inclusion in this log 3. Consider whether any items from the log can be removed.

Issue Update

1. Community IT Recent actions/achievements:

The project to exit the IT support contract with NEL CSU was put on hold due to the COVID-19 pandemic. This has been restarted in recent weeks, with re-planning of the project to accommodate reduced time frames and need for social distancing etc.

The project is now planned to occur in two stages, which are likely to overlap. The first is to upgrade the network infrastructure at 17 community sites where WSFT will take over ‘ownership’ of the networks where we don’t already. This started in July, and should provide a stable network connection at the main community bases.

The second phase is to replace the physical hardware – computers, monitors etc – and move staff over to WSFT systems, email, files and folders etc. This is likely to start in August and continue into September.

We may need to move beyond the initial contract deadline if circumstances change and we are in discussions with our suppliers and NEL CSU in case that occurs.

The team of engineers required to provide this work has been expanded in order to help with the increased workload in a shorter time frame.

We have brought the community paediatric consultants over to WSFT systems ahead of schedule, providing them with all new laptops and other hardware to facilitate digital dictation and remote working during the COVID lockdown.

The other digital transformation that has occurred as a result of COVID-19 continues. This includes video consultations and video meetings, as well as virtual therapy groups. Virtual pulmonary rehab classes are now running, with FIT (following intensive therapy) and cardiac rehabilitation classes next to roll this out.

The two-way link known as the Health Information Exchange (HIE) between the clinical systems in use, SystmOne and e-Care, is now live with health data being shared between the two, and the wider system across to Cambridge, and mid and south Essex. This provides better access to patient information so that our clinicians can bridge the gap between acute and community services more efficiently.

We are also working across the community as a whole to work with a learning management system, Moodle, to provide online education and resources to patients and professionals.


6

Plans for next 3-6 months:

Roll-out of upgraded network infrastructure

Continuation of exit from NEL contract, moving 800+ community staff onto new hardware and support systems. Communication plan to staff:

Continuation of regular Community Digital Programme updates and bulletins

Virtual briefing prior to the hardware upgrades in August.

2. Transport

The new model of service delivery was rolled forwards following an initial three-month extension. However, as with everything, COVID significantly changed the service delivery model so we have been operating in an enhanced way for a number of months. As we plan for recovery post COVID we plan to review the service delivery model with the expectation that the improved levels of service provision are maintained. The numbers of people attending for outpatient appointments has drastically reduced so at the present time it is not possible to evaluate against normal levels. In that context we have seen an improved level of service. Update provided at CoG meeting of 13 November 2019: E-Zec has proposed to change the mechanism for managing discharge activity by dedicating vehicles for sole use by the Trust for this purpose. This would increase the level of control for Trust as we would be responsible for the allocation and logistical management of these vehicles. This model is being used successfully in other acute settings and we have engaged with commissioners and providers in Swindon who manage the non-emergency patient transport in this way. It is anticipated that adopting this model will deliver improvements to the contract as a whole. This proposal includes an overall uplift in additional road based staff (crew) of 25 across the contract (25% increase in personnel) and an additional 14 vehicles (30% increase) to the Suffolk fleet. Vehicles will be allocated to the Trust on a daily basis to manage discharges accordingly. Whilst the detail is being worked through it is anticipated that this will equate to three vehicles dedicated daily at West Suffolk Monday to Friday, and two vehicles at the weekend. Initial conversations with the joint commissioners have been positive although all are in agreement that this must be a system change and equally supported at each acute site. It has been recognised as a positive step which has the potential to significantly improve the performance of NEPTS. The revised model will allow for increased focus and capacity for outpatient appointments, managed and controlled by E-Zec. They will review operations as a whole to allow for potential efficiencies and to support capacity management across the contract outside core hours and when discharge demand is high.

3. Pathology

Agenda item.


Appendix B


7. Chair’s report (enclosed)To receive an update from the ChairFor ReferencePresented by Sheila Childerhouse


Page 1.



SUBJECT: Chair’s report to Council of Governors

AGENDA ITEM: 7


FOR: Information

This has been a most challenging period for the whole of the NHS. We have been fortunate in West Suffolk not to experience a high number of cases of COVID-19. However, even in West Suffolk the impact has meant major changes to the way we work and unfortunately, many delays to routine treatment. I am hugely impressed by the flexibility and commitment that staff have shown in adapting to ensure that patient care is safe and available when needed. There remains an enormous challenge of continuing to treat Covid patients alongside those who have had, and will have, routine treatment delayed while preparing for a winter that is likely to be very tough. Alongside the changes that we have delivered in patient care we have all had to adapt to how we meet, how we interview and how our wider interaction takes place. The fact that tonight‘s meeting is on MS teams is just an example of this. It isn’t the same but thankfully we are getting more proficient at getting the most out of the virtual way of working. You will see from my list of meetings (conversations) that we have enabled many of the routine meetings and interactions to take place. My routine meetings with Chief Executive and with other members of the executive have continued alongside the work of the ICS (all of which is taking place remotely). Since we last met we have appointed a new interim executive chief nurse, Sue Wilkinson, and a new deputy chief nurse, Daniel Spooner. We have also appointed a new non-executive director, David Wilkes, and an associate non-executive executive director Rosemary Mason. They bring a wide set of skills and experience which will of great value to the board - and it is a pleasure to welcome David Wilkes here tonight for his first Council of Governors meeting. Some of you may also have the opportunity to meet our new chaplain, Rufin, he has already had a great impact on the chaplaincy, made external positive links to other religious leaders and created a warm and welcoming environment in the chapel.

Recommendation - Governors are asked to note the report for information.


Page 2.

Annex A: List of meetings attended

Date Meetings and events (01/05/20 until 31/07/20)

01/05/2020 NHS East of England Chairs Meeting via MS Teams

05/05/2020 Telephone Conversation with Rev Rufin Emmanuel

05/05/2020 Telephone Conversation with Helen Beck

05/05/2020 Telephone Conversation with Steve Dunn

06/05/2020 Weekly NED Teleconference Call

06/05/2020 MS Teams Meeting with Will Pope and Susannah Howard

06/05/2020 Council of Governors Meeting via MS Teams

07/05/2020 Telephone Conversation with Prospective NED Candidate


07/05/2020 Telephone Conversation with Jeremy Over

11/05/2020 Telephone Conversation with Gill Jones, Healthwatch Suffolk

11/05/2020 Suffolk & North East Essex STP Chairs’ Group via MS Teams

12/05/2020 MS Teams Meeting with Liz Steele and Florence Bevan

12/05/2020 Telephone Conversation with Kate Vaughton

12/05/2020 Chairs Group Discussion via MS Teams

12/05/2020 Telephone Conversation with Nick Jenkins


12/05/2020 Telephone Conversation with Rev Rufin Emmanuel


13/05/2020 Scrutiny Meeting via MS Teams


13/05/2020 Telephone Conversation with Will Pope

14/05/2020 Medical Staff Committee via MS Teams

15/05/2020 Suffolk & North East Essex STP/ICS Partnership Board via MS Teams

18/05/2020 MS Teams Meeting with Prospective NED Candidate

19/05/2020 Telephone Conversation with Craig Black

19/05/2020 Telephone Conversation with Tara Rose


21/05/2020 Telephone Conversation with Angus Eaton

22/05/2020 MS Teams Meeting with Richard Jones




29/05/2020 Trust Board Meeting via MS Teams

29/05/2020 Charitable Funds Meeting via MS Teams


02/06/2020 Telephone Conversation with Joe Joyce (The Finegreen Group)


03/06/2020 Telephone Conversation with Gary Norgate


03/06/2020 Head of Communications Presentations to Senior Leaders via MS Teams


04/06/2020 Telephone Conversation with Paul Pearson, UNISON

04/06/2020 Mediation Discussion via MS Teams

04/06/2020 Chaplaincy Meeting via MS Teams

05/06/2020 Telephone Conversation with David Harrison, ICS

08/06/2020 Telephone Conversation with Alan Rose









Page 3.


10/06/2020 MS Teams Meeting with Ed Garratt, Steve Dunn and Will Pope

10/06/2020 MS Teams Induction Meeting with Sue Wilkinson, Interim Chief Executive Nurse


12/06/2020 Suffolk and North East Essex STP/ICS Partnership Board via MS Teams

12/06/2020 SNEE ICS Thinking Differently Together Event via MS Teams


15/06/2020 Telephone Conversation with Sue Smith

16/06/2020 Telephone Conversation with Lucy Hampton

16/06/2020 MS Teams Meeting with Steve Dunn



17/06/2020 MS Teams Meeting with Nick Jenkins






18/06/2020 MS Teams Meeting with Ann Radmore

19/06/2020 Extraordinary Closed Board Meeting via MS Teams


23/06/2020 MS Teams Meeting with Craig Black

23/06/2020 MS Teams Meeting with Val Dutton



23/06/2020 MS Teams Induction Meeting with John Troup, Interim Head of Communications

23/06/2020 NHS East of England Chairs Meeting via MS Teams





24/06/2020 Telephone Conversation with Sue Wilkinson


25/06/2020 Telephone Conversation with Joe Joyce (The Finegreen Group)

25/06/2020 Telephone Conversation with Liz Steele

25/06/2020 FT Nominations Committee Meeting via MS Teams


30/06/2020 MS Teams Meeting with Craig Black

30/06/2020 MS Teams Meeting with Richard Jones and Jeremy Over


30/06/2020 NHSE&I Oversight and Support Meeting via MS Teams


01/07/2020 Telephone Conversation with Louisa Pepper



01/07/2020 Improvement Board via MS Teams

02/07/2020 NED Interviews via MS Teams

03/07/2020 Telephone Conversation with Richard Davies

06/07/2020 MS Teams Meeting with Susannah Howard


07/07/2020 Telephone Conversation with Gill Jones, Healthwatch Suffolk


07/07/2020 MS Teams Meeting with Lucy Hampton




Page 4.


07/07/2020 Closed Council of Governors Meeting via MS Teams



08/07/2020 Chairman’s Appraisal via MS Teams



09/07/2020 Medical Staff Committee via MS Teams

10/07/2020 MS Teams Meeting with Steve Dunn, Helen Beck, Jeremy Over and Alastair Currie

13/07/2020 Introductory Meeting with External Review Team via MS Teams

13/07/2020 Improvement Programme Board via MS Teams



14/07/2020 External Review Discussion via MS Teams

14/07/2020 1:1 with Helen Beck

14/07/2020 1:1 with Steve Dunn


15/07/2020 Alan Rose Appraisal via MS Teams

15/07/2020 Louisa Pepper Appraisal via MS Teams

15/07/2020 MS Teams Meeting with SJ Relf, e-Care/GDE Operational Lead


15/07/2020 Telephone Conversation with Liz Steele

20/07/2020 Angus Eaton Appraisal via MS Teams

20/07/2020 External Review Discussion via MS Teams


21/07/2020 MS Teams Meeting with Val Dutton


21/07/2020 Richard Davies Appraisal via MS Teams


22/07/2020 Gary Norgate Appraisal

22/07/2020 MS Teams Meeting with Louisa Pepper

22/07/2020 MS Teams Meeting with SJ Relf and the NEDs


23/07/2020 East of England Regional Roadshow via MS Teams

23/07/2020 MS Teams Meeting with Nick Jenkins

27/07/2020 External Review Meeting

28/07/2020 1:1 with Richard Jones

28/07/2020 1:1 with Helen Beck

28/07/2020 MS Teams Meeting with Alison Wigg, East of England Ambulance Service NED

28/07/2020 1:1 with Steve Dunn

29/07/2020 ICS Thinking Differently Together Event via MS Teams



31/07/2020 Audit Committee via MS Teams


8. Chief executive’s report (enclosed)To note a report on operational andstrategic mattersFor ReferencePresented by Craig Black


Page 1

Council of Governors – 11 August 2020

I am conscious of the Governors’ role in contributing to strategic decisions of the organisation and in doing this representing the interests of our Members as a whole and the interests of the public. Within this report I have reflected some of the key messages from my report to the Board of Directors, but aim to highlight some of the key strategic issues and challenges that the organisation is addressing. Happy 72nd birthday NHS in what has been the most challenging year in NHS history. Over the last few months the NHS has stepped up in ways never seen before to work out how to deliver services differently following lockdown, recruit tens of thousands more staff, returners and volunteers and even build hospitals to respond to the COVID-19 global pandemic. But the unprecedented challenge facing the NHS would have been made all but impossible without the help and support of countless individuals and organisations around the country, the key workers, from bus drivers and refuse collectors to care givers and shop workers. And the public too, who embraced the lockdown measures to help protect the NHS and their communities, whether by staying at home, helping their neighbours with the shopping, maintaining social distancing or washing their hands more often. The NHS is grateful to the nation for its efforts – great and small. Over the last few weeks we have been undertaking a major engagement exercise across the organisation under the banner of ‘What works for you'. There has been an amazing response, with 1,380 staff completing the survey and more than 50 workshops and interviews held so far too. As part of this work, we are also looking at how we can engage with our colleagues that are shielding at home.

What staff have said What we will explore in the workshops

The importance of genuine appreciation.

What can we do to make staff feel really valued and supported in your roles?

The importance of leadership and the impact this can have on people when done well.

Discussions around what staff would like to see from leaders - what should they be focused on doing and how should they treat staff?

The impact of strong team working. How can we help staff teams to develop even stronger bonds and feelings of mutual support?

AGENDA ITEM: 8

PRESENTED BY: Craig Black, Deputy Chief Executive Officer

PREPARED BY: Steve Dunn, Chief Executive Officer

DATE PREPARED: 4 August 2020

SUBJECT: Chief Executive’s Report

PURPOSE: Information


Page 2

Communications – for some staff the communications throughout the pandemic has worked well, but some of you have struggled.

Discussions around how we can best communicate with staff and their teams. What works for staff and what doesn’t?

Returning to normal – some staff have said you are tired and feel cautious about returning to a world beyond COVID – including home working colleagues.

How do we support staff through this next part of the COVID journey? How do we keep the good bits and lose what isn’t working? How do we protect staff and their teams?

The information and suggestions gathered from this important work will inform and feed into multiple work streams, including the refresh of our future strategy, our COVID recovery plans, quality improvement, and our focus on wellbeing. It will even influence how we work in the plans for the new hospital. The engagement that we are undertaking with our staff is an important part of our response to the concerns raised earlier this year by the CQC. The external review’s investigation of the issues raised in this report has now recommenced and we are working closely with the team to support this important work and ensure that we are best place to learn and improve from this experience. Building a culture where everyone feels confident and safe to speak up and raise concerns is of the utmost importance across the NHS, and of course to us here at WSFT, and we are looking for our new lead Freedom to Speak Up Guardian to help us achieve this. We are currently seeking expressions of interest and recruiting to the important Guardian role and I wanted to highlight and thank Dr Francesca Crawley who has become our acting lead Freedom to Speak Up Guardian until we recruit to the role. As acting lead, Francesca is available to all staff as an independent and impartial source of advice at any stage of raising a concern. To help her carry out the role she has access to anyone in the organisation, including myself, or if necessary, outside the organisation. In June, the first staff forum for the newly created BAME Network at the Trust took place, with over 30 participants attending virtually over Microsoft Teams. The session, which lasted just over an hour, was led by chair of the network Dr Ayush Sinha. Dr Sinha also gave a presentation to attendees about the importance of the establishment of a BAME network and how the network aims to ensure career opportunities and experiences of work are not predetermined by ethnicity, nationality or race. Myself and other members of the executive team attended, answering a wide array of questions from participants about such as positive working environments as well as addressing any concerns. There was a very positive vibe around the first forum and Dr Sinha as well as deputy chair of the network, Balendra Kumar, have extended a big thank you to everyone who attended to make the opening meeting a success. Forums will take place on a quarterly basis and all BAME and non-BAME staff are welcome to attend. Future events will see different speakers and topics to be addressed with future dates being advertised in Green Sheet. Happy Eid al-Adha to colleagues and friends. Eid al-Adha ('The Festival of Sacrifice'), is the most important feast of the Muslim calendar. The festival may also be known as Eid al-Kabeer, which means 'The Grand Eid' or Eid el-Lahma (’The Festival of Meat’). It has this more important status as, in religious terms, this Eid lasts for four days, whereas Eid al-Fitr is one day, even though most countries observe about the same number of public holidays for both Eids. This festival is celebrated throughout the Muslim world as a commemoration of Prophet Abraham's willingness to sacrifice everything for God. Eid al-Adha falls on the tenth day of Dhu al-Hijjah, the twelfth and final month in the Islamic calendar. Members of WSFT’s community team received a welcome morale boost in July when Secretary of State for Health and Social Care, Matt Hancock MP, made a flying visit to Newmarket. Mr Hancock was making his first visit to his parliamentary constituency since the start of lockdown and had crews from BBC Look East and ITV Anglia in tow. After a whistle-stop tour of Newmarket High Street, the Minister headed up Exning Road to the town’s community hospital to thank staff for their sterling efforts during the coronavirus pandemic.


Page 3

You have no doubt witnessed the Black Lives Matter movement which has occupied our television screens in recent weeks. The unlawful killing of George Floyd has shocked people all over the world and seen many more stand together to fight both the legacy and the ongoing reality of injustice, racism and discrimination. The movement is even having an impact very close to us in Suffolk, with protests being held in Ipswich and Bury St Edmunds last weekend. It’s clear to see that individuals across this country and all the world are determined to change how black people, and other people of colour, are treated in everyday life. This is a determination that needs our support. What is more, it is clear that COVID-19 has taken a disproportionate toll on our Black, Asian and Minority Ethnic colleagues and this has been a cause of very real anxiety which we have been trying to respond to through our enhanced risk assessments and sensitivity to staff’s needs. It seems more than ever before that we need to show leadership and support for those that are disadvantaged as a result of the colour of their skin. As a Trust, we are exceptionally proud of the diversity of our staff, our volunteers and our patients. We could not do all that we do without the dedication and commitment of all our staff, whatever their background - I sincerely mean this. The NHS belongs to us all and is there for all of us in our time of need. The NHS should role-model the type of society we want and the respect and appreciation of all, whatever the job you do or whatever your background. Our Trust and our NHS belongs and serves communities of all backgrounds, cultures and skin colours. And that’s why we need to collectively listen to the experiences of Black, Asian and Minority Ethnic people, because it is clear that we still do not appreciate the challenges they have faced or face, nor supported them to fulfil their potential. It’s clear from the protests across the globe that people have not been listened to properly and injustice and discrimination are still rife. All too often we are guilty of making assumptions about other people and not taking the time to truly understand what it is like to walk in their shoes. As part of our response to COVID-19 we continue to take a wide range of actions to support patients, carers and our staff. During our COVID response we have continued the work to survey our reinforced autoclaved aerated concrete (RAAC) and address these findings. I want to recognise the support and commitment of our staff to ensure this work continues at a time when operational pressures are already so challenging. Over the last few weeks a team of structural engineers having been carrying out a structural survey of the external RAAC wall planks around the outside walls of this hospital. This part of the project has now been completed and it’s time to go inside the hospital and carry out the same structural survey of all the external walls within the hospital’s 20+ courtyards. We are currently planning to work our way around the hospital clockwise. This will mean that for the next few weeks the survey team will have to transport scaffolding equipment along the corridors of the ground floor of the hospital at varies times of the day. Our plan will be to try and inform the departments/wards that may be affected by this work in advance, but as this work will sometimes be affected by bad weather we may not be able to in some cases. I was delighted to Chair our new improvement programme board in July which includes representatives from the clinical commissioning group (CCG) and the regional office. A report from the meeting and a report on the Trust improvement plan is included on the agenda. As previously indicated in April 2020, East Suffolk & North East Essex NHS Foundation Trust (ESNEFT) announced that the current North East Essex & Suffolk Pathology Service (NEESPS) networking arrangement with the Trust will cease no later than 31 October 2020. A joint working group has been set-up between ESNEFT and WSFT to oversee the transition and to work on finding an alternative solution to the current arrangements. Multiple workstreams continue to ascertain how the future of WSFT pathology networking is designed. A pathology transformation lead has now been appointed to oversee the dissolution and further develop the transformation of the pathology services at WSFT. The Trust and Glemsford Surgery have embarked on a special project to work together to improve patient care, and have now officially joined as integrated partners in healthcare. From the buildings to the staff, we will support the surgery and work together to create a new, innovative, strong and sustainable healthcare service in Glemsford and the west of Suffolk. Together we will


Page 4

deliver safe, effective and more joined up models of care, ensuring patients receive the right care, in the right place at the right time. There are a wide array of benefits from this new partnership project, and at the heart of them all is patient care. The traditional barriers between hospitals, GPs and community services will be removed. For example, patient records will be able to be shared between providers. This and other quality improvements from working seamlessly together will allow GPs and our staff to jointly identify and address population health issues. We look forward to working alongside Glemsford Surgery colleagues to reap the benefits of this closer working relationship.

After the success of cataract go live in 2019, the intention was to go live with glaucoma and medical retina in May or June this year. There was concern that COVID-19 might derail these plans when lockdown started in March. However, reduced clinical throughput created a perfect opportunity to go live with no further reduction in patient numbers. Thanks to support from the IT projects team and the supplier, ABEHR Digital, the system was configured, tested and went live on 11 June. The scope was expanded and, in addition to glaucoma and medical retina, the go live included general clinics and eye emergencies, meaning that approximately two thirds of the eye treatment centre workload is now in OpenEyes. The benefits are already being seen: streamlined virtual clinics and simple, easily generated correspondence to patients, GPs and optometrists (using OpenEyes, one of our secretaries was able to generate 28 letters in just over 40 minutes). Thank you to everyone who has been involved in this project, including IT, the team at ABEHR and our colleagues in the eye treatment centre for their patience and willingness to embrace new ways of working.

I urge our community to continue to adhere Government to advice including social distancing and wear masks to protect themselves, others and allow us to continue to meet the needs of our patients and population. This is a shorter report than normal but I wanted to take the opportunity to say thank you to our community and our amazing staff.


9. Governor issues (enclosed)To note the issues raised and receive anyagenda items from Governors for futuremeetingsFor ReferencePresented by Liz Steele




SUBJECT: Governor issues

AGENDA ITEM: 9

PREPARED BY: Liz Steele, Lead Governor

Richard Jones, Trust Secretary & Head of Governance

PRESENTED BY: Liz Steele, Lead Governor

FOR: Approval

Response to feedback from Liz Steele, following informal Governors meeting on 27 July 2020. 1. Despite being assured at a previous governors meeting that the practice of discharging

elderly patients late at night had been reviewed; especially as a care plan should be in place it is disappointing to discover that this is still happening. Therefore, in future can governors be confident that the appropriate procedures are being followed. We are reviewing available data on this issue, including incidents, complaints and patient flow. This will focus on the discharge of patients from inpatient areas, not patients who have attended the emergency department. We will include any specific cases that Governors are aware of as part of this review. ACTION It is proposed that a report be considered at the Engagement Committee and this discussion is then reported to CoG.

2. Can governors be assured that staff, unused to working in those areas where patients are most unwell, and who have a higher mortality rate, are supported both during and after their work A staff support psychology service was set up in response to the COVID-19 pandemic and subsequently a business case has been approved to consolidate, enhance and sustain this service in order to meet the ongoing psychological needs of our staff. We know which wards meet this description, and we have pro-actively provided pastoral and psychological support to these teams. Stress related sickness is the second highest cause of staff absence and is likely to increase in the immediate aftermath of the first wave of the pandemic. Having a high quality, responsive, in-house staff support team enables us to support staff in acute distress and continue to support them through their recovery and return to work, supporting staff to feel valued and cared-for by the Trust. Improving staff wellbeing has positive impacts on patient safety, staff morale and effectiveness and the ability to access the right support at the right time will reduce the length of time that staff are unwell. Providing the service ‘in house’ also allows for system and team learning as well as individual interventions. With an inhouse service the Trust is also better able to respond to and address issues that are negatively impacting on staff wellbeing. The business case approved the provision of additional staff to enable the staff psychology support team to continue to provide the service as currently configured, to roll out a training and support programme for managers and leaders and embed reflective practice into the culture. The case also supports the delivery of short-term specialist trauma and therapy services for those affected by the


pandemic. Part of the business case approval included evaluation of effectiveness of the service over the next two years.

3. We are aware that patient privacy has always been an issue due to the structure of the hospital, so what mitigating factors will be put in place to improve this Lack of single rooms creates privacy, dignity and infection prevention challenges for the Trust. There are procedures in place to manage this within the structural limitations and these are used by the patient flow, infection prevention and clinical teams to balance the needs of patients and their loved ones as best we can. We use the butterfly symbol to identify end of life patients and will always aim to give priority for these patients and families using single rooms, recognising the overriding need to maintain appropriate infection prevention safeguards. Clinical areas also have designated quiet rooms which are used to discuss sensitive issues with patients and families. During our COVID response this positive has been exacerbated by our need to continue the work to survey our reinforced autoclaved aerated concrete (RAAC) and address these findings. The support and commitment of staff has been recognised to ensure this work continues at a time when operational pressures are already so challenging. Assessing the RAAC planks and mitigating findings remains the significant priority for the estates and operational teams. However, we continue to do all we can to maintain privacy and dignity within our existing facility. Proposal That a joint development session is scheduled to provide the Governors with Board members and partners a more details briefing on the plans for the development of a new health and care facility.

4. How can we be assured that information provided to/researched by the NEDs is full and accurate (such as the response given to an earlier question, that there is a link between WSFT and Addenbrookes pathology; however, the length of time some of the results take to come back has demonstrated that there is not a full link between sites- which was the answer previously provided). Are the NEDs assured that they have been given/researched the whole picture NEDs to have a reflective discussion with the Governors on this question.

5. Can clarification be provided regarding the VAT refund - and not applying/offering this to staff-and what the process was to agreeing the current situation with staff in not passing this on Below is the information sent out to all staff as part of the Staff Briefing on 15 July. The decision not to pass on the change in VAT was considered and approved at the COVID Strategic Meeting on 14 July. This meeting includes a range of senior clinical and non-clinical staff and the approach was fully supported. It is our understanding that the Trust’s approach is consistent with other NHS organisations and we have not received adverse feedback from staff.

Reduction in VAT

As you may be aware, the Chancellor announced last week that he was cutting VAT in the

entertainment and hospitality sectors from 20 per cent to five per cent.

The reduction in VAT, which will run until January 2021, comes into effect today.

As hospital catering outlets are included in the VAT cut, we have to decide how to implement it across

Time Out, the Courtyard Café and our vending machines.

Income across the trust’s catering outlets has dropped by £90,000 per month during the pandemic and

this is not forecast to change for the foreseeable future. The change in VAT will save around £5,000 per


month.

Over the last few months we have endeavoured to both provide support and demonstrate appreciation to

the thousands of staff who have had to endure changes to normal ways of working and really challenging

circumstances across the entire organisation.

Whilst it will never be enough, we have provided free coffee to all staff and free meals to night staff. We

have also kept prices across the Trust stable despite some costs increasing.

We will seek to maintain this level of support for as long as we can and are planning to use the change in

VAT as a way of prolonging these measures. I hope that you will agree that the prices within our outlets

already represent good value and that the support initiatives are worth continuing.

6. Can we be assured that the trust is keeping people informed at every stage of their patient

journey [within ED]? (e.g. at the front waiting area there is no idea of length of wait [following triage] - this was picked up at an earlier quality walk round). How can the governors be assured that actions discussed are acted upon? The length of wait will vary depending on the patient need so it would not be possible to indicate a single time to cover all patients who are waiting e.g. those waiting for an ENP might be in a shorter queue than those waiting for a doctor. This will be discussed with the ED team more generally about how they keep patients informed and what else we could do. ACTION Feedback from this discussion will be shared with Governors.

7. We are aware that there has been a huge amount of work cancelled and a subsequent back log, please can we know what the process is, time frame to manage this and how will this be communicated to the public As has been outlined in COVID reports to the Board and summarised in the paper on today’s agenda the recovery is expected to take a number of years and we are not yet in a place where we fully understand the true post COVID capacity and demand. There is a significant focus regionally and nationally on this but the work is iterative as guidance changes and demand increases. Post-COVID capacity is less than pre-COVID capacity and hence recovery of backlogs will be extremely challenging for those needing surgical procedures. Outpatient based specialties are already starting to recover. All patients waiting for treatment have been written to individually informing them of how to seek help if their condition changes and harm reviews have been undertaken on all patients exceeding 52 weeks.

Recommendation:

1. To note the response to the issues raised


10. COVID report (enclosed)To note the summary reportFor ReferencePresented by Richard Davies


Page 1.



SUBJECT: COVID-19 report

AGENDA ITEM: Item 9

PREPARED BY: Helen Beck, Executive Chief Operating Officer

PRESENTED BY: Richard Davies, Non-Executive Director

FOR: Information

This report is based on the report received by the Board on 31 July.

This paper provides an update of current levels of Covid and other emergency activity across the Trust as well as indications of diagnostic and elective activity levels and recovery planning. Some highlights around community services have also been included and ahead of a full report at September Board of Directors this paper also provides a summary of actions to support Black Asian and Minority Ethnic Groups across the Trust.


Page 2.

Covid-19 Planning and Response

1. Current Capacity Situation Critical Care – we continue to manage critical care patients in the main unit and have not needed any additional capacity since the start of July. Plans to use regional surge centres however appear not to be supported by the region and hence should a second wave materialise we may need to reoccupy the second unit. Staffing of these additional beds would have a significant negative impact on our ability to run our elective programme. General and Acute Beds – isolation capacity remains consistent across wards F12, F7 and G4. At the time of reporting within this bed base we currently have three confirmed Covid patients with a further 17 awaiting a swab result, plus 11 patients with negative swab results but who have been clinically designated as Covid. Non elective Activity - ED attendances and emergency admissions are increasing but have still not reached pre-Covid levels. Stranded patient number have increased which has a negative impact on patient flow. Further work is underway to address this issue.

2. Phase 2 Activity and Backlog Levels May - July 2020 In line with national guidance we are continuing to step up more urgent clinical services, but despite this our backlogs continue to grow and our usual performance metrics continue to show a deteriorating position. Summary of RTT backlog: At the end of June the total waiting list size had increased to 18,267 with 483 patients over 52 weeks and performance at 48.45%. This position will continue to worsen. In terms of first outpatients we have in excess of 6,000 patients waiting for a first appointment, with the biggest numbers being in ENT/Audiology, Ophthalmology, Orthopaedics, Urology and Dermatology. Summary of Cancer backlog The number of 104 day waits for cancer treatment continues to be higher than normal at 70 (up from 68 in June). 47 of these are within Colorectal due to Endoscopy delays, but most of these patients now have dates and we are working through this backlog as a priority. All the 104 day waits are being reviewed for clinical harm once they have a diagnosis. The 104 day waits may continue at a higher rate as we are investigating and treating patients with the biggest clinical concerns rather than by waiting times. Within lower GI this will mean investigating those with a FIT+ test first. There is currently adequate access to main theatres for cancer patients, but this may become a risk as we start to receive higher referrals and diagnose more cancers. We are still only receiving around 70% of our baseline referrals. MRI, CT, ultrasound and endoscopy investigations would usually be completed in line with the 6 week diagnostic standard. Whilst the CT backlog has increased slightly there have been notable reductions in endoscopy and MRI backlogs as activity restarts in line with our recovery plans. This will have a significantly positive impact on our cancer pathways however as yet we remain some way off the 6 week diagnostic standard. The diagnostic team are finalising a detailed recovery plan but inclusive of additional resource and insourcing options we do not expect to recover the waiting time standard before the turn of the year.


Page 3.

Recovery Planning The wider recovery planning continues and we are starting to see an increase in delivered activity. However, as expected, this recovery is slow. Outpatients - whilst there has been a steady increase in OPD activity since the middle of April the total volume of appointments is significantly below pre-Covid levels. Furthermore, whilst face-to-face OPD clinics have largely ‘re-opened’, with appropriate social distancing measures, there is further scope for virtual clinic adoption. This will be a key workstream in the Phase 3 recovery activity. Theatres - activity is now increasing following the opening of day surgery unit (DSU) on 13 July and a fourth list in main theatre. It is anticipated that the volume of activity that will be seen in DSU will increase quite rapidly following the initial opening phase. Our recovery remains in line with our anticipated activity plans. Furthermore, we are making good use of the BMI for Breast, Plastics, General Surgery, Pain, T&O and endoscopy and have now added an additional patient to each list as teams adapt to the new COVID procedures. Clinicians have been conducting harm reviews on patients and we have received additional national guidance around this and will be working to ensure our processes are compliant. Letters have also been sent to patients waiting for surgery to explain the limitations of current services and manage expectations. At a system level we are working with other providers to offer alternative pathways or manage risk through the provision of advice and guidance, therapy support or the provision of aids.

3. Phase 3 Recovery Planning Our phase 3 recovery plans are being iterated on an ongoing basis with system partners. The most recent submission, on 15 July, made minor adjustments to our elective and diagnostic plans and provided greater detail around Paediatric ED attendances, minor ED attendances, bed occupancy and cancer recovery plans. Whilst we generally remain on track with these plans there are a number of key constraints which have emerged: 1. Limited capital funding which hinders delivery of enhanced elective recovery in the

medium to long term (specifically for the Newmarket elective hub). 2. Reduced ability to access regional surge centres in the event of a local surge in critical

care demand (this is subject to further conversation as an emergent theme despite it featuring as a core element of our recovery plan since the first submission).

3. Impact on the elective recovery plan of 2 above (i.e. the impact on delivering the recovery plan through necessary use of additional critical care surge capacity on site).

4. Impact on the elective recovery plan of the ongoing RAAC plank investigation / mitigation plans.

5. Impact of limited on site Covid testing. This has a disproportionate impact on patient flow as it delays discharge in some cases and delays the release of capacity on contact bays where discharges have already occurred.

These constraints / challenges are a significant focus of our future planning effort and more specifically our winter plans. Planning for winter has commenced and will report to the board separately. In the event of a second Covid surge the winter period could be one of the most difficult the NHS has faced for many years, if not ever. Testing The lack of on-site testing remains a major challenge. Unfortunately, the cost per test (>£150) has meant we have chosen not to pursue the procurement of the available ePlex analyser. We are still trying to make an appropriate molecular microbiology capital purchase but availability of both analysers and reagents continues to be a challenge.


Page 4.

In June we transferred over to Source Bioscience as our provider for staff and patient PCR testing. This initially improved turnaround times but we have now been informed that their contract with the NHS will not be renewed at the end of July and we are currently sourcing an alternative NHS provider. ESNEFT have supported us with a small amount of testing capacity over the past week along with supplying some Cephid reagents for on-site use from their limited supplies. Unfortunately, as there is no IT link between ESNEFT and WSFT this limits the option to move testing to them on a permanent basis due to the significant transcription involved in the manual process. On a positive note we are progressing with the validation of some SAMBA point of care testing devices which will give us a limited on site capacity in the near future. Community Services Within our paediatric community services we have continued to support those patients on our caseload where there may be safeguarding concerns and we have contributed remotely to safeguarding case conferences. The paediatric team are also trialling an IT platform called Moodal, as a key development to support parent groups. The team have indicated that this will transform their ability to provide support to parents going forward if the business care is supported. The adult pulmonary rehab team were successful in a funding bid to Active Suffolk to fund equipment to support virtual rehab classes. Supported by Sarah Judge and the IT team they have become recognised nationally as trailblazers in providing virtual interactive groups. The autistic spectrum disorder (ASD) diagnostic pathway has been significantly negatively impacted by Covid service restrictions. Supporting our Black, Asian and Minority Ethnic colleagues As we have previously reflected on, emerging evidence shows that black and minority ethnic (BME) communities are disproportionately affected by COVID-19, particularly those with comorbidities who are presenting adverse outcomes at a younger age. The reasons for this are not yet fully understood, but the health inequalities present for BME communities have long been recognised. It is imperative that we are assured as to the effectiveness of our response to this workforce risk, and a full briefing paper developed in partnership with our BAME Staff Network Chair will be presented to the Board of Director in September. This update provides an interim report of progress to date. National direction and data returns On 24 June 2020 NHS England wrote to all NHS organisations to promote the crucial importance of staff health risk assessments. This was in response to a national-level concern that NHS staff might not be benefitting from a risk assessment process. The letter rightly set the expectation of “significant progress” being made on this within the following month. Situation at WSFT With the support and input of our occupational health team, a staff health risk assessment process has been in place at WSFT since 19 March. This risk assessment tool has been updated throughout the pandemic as the evidence base has developed. As the understanding of the risks became more apparent, our Strategic COVID group determined in late April that completion of the risk assessment should be mandatory for all staff and set a 18 May timeframe for completion. This yielded a response of 90% completion.


Page 5.

The national data collection requirement has provided the opportunity to review our data and ensure that every single member of staff has benefitted from a risk assessment discussion. The interim position submitted on 17 July was as follows:

Question Response

1. Have you offered a risk assessment to all staff? Yes

2. What percentage of your staff have you risk assessed? 95%

3. What percentage of risk assessments have been completed for staff who are known to be ‘at risk’?

93%

4. What percentage of risk assessments have been completed for staff who are known to be from a BAME background?

91%

The number of completed assessments is 5,062. The 5% of staff where we have not yet confirmed completion of a risk assessment equates to 268 individuals and these are being followed-up. Of this 268, 63 are known to be of BAME background. Further assurance will be provided to the Board in September, including the feedback from BAME staff that has been gleaned through the Trust-wide “What Matters to You” staff engagement work – which was completed at the end of July.


11. Quality and performance report(enclosed)To note the reportFor DiscussionPresented by Angus Eaton




SUBJECT: Summary quality & performance report

AGENDA ITEM: 11

PREPARED BY: Helen Beck, Chief Operating Officer Sue Wilkinson, Chief Nurse Richard Jones, Trust Secretary & Head of Governance

PRESENTED BY: Angus Eaton, Non-Executive Director

FOR: Information - To update the Council of Governors on quality and operational performance

A revised quality and performance report has been reviewed and developed by the Board since March 2020. This reflects the changing landscape and the need to provide meaningful data for the activity taking place. Indicators are reporting in the following areas:

- Access - COVID-related - Patient safety - Patient experience - Community services - Acuity measures - Perfect ward

The highlights from the Board discussion were:

- Access performance including the time distribution of patients waiting for treatment (RTT) and the concerning rise in patients waiting more than 52 weeks. It was agreed to develop trajectories with assumptions for key standards to support an assessment of progress against plan

- Increasing emergency department (ED) attendances - Additional community information was reviewed, this had been added to the report to

ensure greater oversight. National concerns regarding children in care were recognised and this is being reviewed by the team to address the potential unmet need. It was noted that in some circumstances the use of video consultations allows the service to be more responsive but this is not always possible or appropriate

- It was agreed to flag metrics in the report which are national standards and which are local.

- Duty of candour performance was reviewed and the plans in place to improve performance. It was confirmed that all but one of the verbal duty of candour have been completed for patients with hospital acquired Covid-19

- It was also noted that we have had a near miss never event. The detail of the case relating to an anaesthetic block was reviewed with the CCG to provide an independent view of this judgement. A full investigation will be undertaken


Summary quality and performance report Page 2

- Acute falls per thousand bed days has increased, it was seen as reassuring that 89% of patients who fell had a falls care plan in place but this will be maintained as an area for improvement. A range of interventions to support improvement were discussed including: a falls leads starting in the role by end of August, new falls mats being trialled on a number of wards, the falls groups focus on Trust-wide learning from falls with harm

- Pressure ulcers in the community is a concern and these incidents are being reviewed in detail. It was recognised that in some cases patients can receive excellent care but pressure ulcers can still develop or deteriorate. Approaches to education and support for patients and famiies is being developed as part of the learning. Following changes in the service during Covid the return of the tissue viability team to their community service is expected to support improvement

- An improvement in the malnutrition universal screening tool (MUST) nutrition assessments was welcomed and will continue to be a focus for sustained improvement

- New complaints have started to increase in July, but the patient experience team is now fully established to ensure we are able to respond appropriately and ensure trust-wide learning. Communication with patients and relatives was recognised as a theme over recent weeks and this will be the focus of shared learning. Discussion took place on the future provision of the ‘clinical help line’ service which had been very successful. It was noted that this service had been established from staff that had been redeployed during Covid, and that as clinical services increase these staff are being asked to return to their normal roles. Consideration is being given as to how we can continue to provide this service and the staffing requirement

The quality and performance report will continue to be developed so that at the next Board meeting the report provides more granular details for a wider ranges of indicators. In addition, more detailed reports were received in July by the Board of Directors regarding:

- maternity services This included: the maternity dashboard; maternity safety highlight report; local audit / monitoring of compliance with Section 29A letter indicators; and other maternity indicators. Submissions to support the NHS Resolution (NHS risk pooling insurance scheme) maternity incentive scheme was also received and approved.

- infection prevention assurance framework. The NHSE framework sets out how trusts can assess measures taken in line with current guidance to provide a level of board assurance, including to provide evidence and as an improvement tool to optimise actions and interventions. The Trust has undertaken self-assessment against the framework including review of estates and isolation facilities. Initial self-assessment highlighted three areas of non-compliance: ventilation, timely receipt of testing results and isolation. Detailed review has identified three further areas where we cannot confirm full compliance without further audit or review - patient moves, contact tracing, and timely taking of swabs. This does not mean that the trust is necessarily non-compliant but it would benefit from scrutiny before making any declarations and action is being taken to address this.

Recommendation: To note the report.


12. Summary finance & workforce report(enclosed)To note the summary reportFor ReferencePresented by Alan Rose




SUBJECT: Summary Finance & Workforce Report

AGENDA ITEM: 12

PREPARED BY: Nick Macdonald, Deputy Director of Finance

PRESENTED BY: Alan Rose, Non-Executive Director

FOR: Information - update on Financial Performance

EXECUTIVE SUMMARY: This report provides an overview of key issues during Q1 and highlights any specific issues where performance fell short of the target values as well as areas of improvement. The format of this report is intended to highlight the key elements of the monthly Board Report.

The plan for the year is to break even. This includes receiving all FRF and MRET funding associated with meeting our Financial Improvement Trajectory (FIT – formerly “Control total”).

The Trust has been reimbursed with all costs relating to COVID 19

Given the unusual nature of the current financial year our focus is on our underlying income and expenditure position in readiness for 2021-22

Income and Expenditure Summary as at June 2020 The reported I&E for June is break even, in line with NHSI guidance. Due to COVID-19 we are receiving a top up payment that includes MRET and FRF and ensures we break even. The value of this for June was £3.4m (£10.2m YTD). In order to deliver the Trust’s control target in 2020-21 we needed to deliver a CIP of £8.7m (3.4%). The plan for the year to June was £2.247m (25.8% of the annual plan) and we achieved £1.148m (13.2%). This represents a shortfall of £1,099k which is recovered within the top up payment.

Performance against I & E plan

Budget ActualVariance

F/(A)Budget Actual

Variance

F/(A)Budget Actual

Variance

F/(A)

£m £m £m £m £m £m £m £m £m

NHS Contract Income 19.1 18.1 (1.1) 55.3 54.1 (1.2) 227.2 227.6 0.5

Other Income 2.8 3.0 0.1 8.8 9.0 0.2 36.3 37.1 0.8

Total Income 22.0 21.0 (1.0) 64.1 63.2 (1.0) 263.4 264.8 1.3

Pay Costs 15.5 15.6 (0.0) 48.6 48.1 0.5 201.8 206.1 (4.3)

Non-pay Costs 8.4 7.9 0.4 21.3 22.4 (1.1) 91.3 88.3 3.0

Operating Expenditure 23.9 23.5 0.4 69.9 70.5 (0.6) 293.1 294.4 (1.3)

Contingency and Reserves 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

EBITDA excl STF (1.9) (2.5) (0.6) (5.8) (7.3) (1.6) (29.7) (29.7) 0.0

Depreciation 0.7 0.6 0.1 2.0 1.8 0.2 8.1 8.1 0.0

Finance costs 0.3 0.3 0.0 1.0 1.0 (0.0) 3.9 4.0 (0.1)

SURPLUS/(DEFICIT) (2.9) (3.4) (0.4) (8.8) (10.2) (1.4) (41.7) (41.7) (0.1)Provider Sustainability Funding (PSF)

PSF / FRF/ MRET/ Top Up 2.9 3.4 0.4 8.8 10.2 1.4 41.7 41.7 0.1

SURPLUS/(DEFICIT) incl PSF (0.0) (0.0) (0.0) 0.0 (0.0) (0.0) (0.0) (0.0) 0.0

SUMMARY INCOME AND EXPENDITURE

ACCOUNT - June 2020

June 2020 Year to date Year end forecast


2

Performance against Income plan

The chart below summarises the phasing of the clinical income plan for 2020-21, including Suffolk Community Health. This phasing is in line with activity phasing and does not take into account the block payment.

Performance against Expenditure plan - Workforce

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

£k

2020/21 Phasing of clinical income

19/20 20/21 Plan 20/21 Actual

Monthly Expenditure (£)

As at June 2020 Jun-20 May-20 Jun-19 YTD

£000's £000's £000's £000's

Budgeted Costs in-month 15,541 17,555 13,436 48,609

Substantive Staff 13,762 15,187 12,678 42,653

Medical Agency Staff 130 237 163 519

Medical Locum Staff 320 262 245 871

Additional Medical Sessions 359 378 200 1,001

Nursing Agency Staff 91 69 191 330

Nursing Bank Staff 464 406 324 1,294

Other Agency Staff 41 52 95 154

Other Bank Staff 201 189 138 589

Overtime 132 200 176 445

On Call 87 65 76 218

Total Temporary Expenditure 1,824 1,858 1,607 5,421

Total Expenditure on Pay 15,587 17,046 14,285 48,074

Variance (F/(A)) (46) 509 (849) 535

Temp. Staff Costs as % of Total Pay 11.7% 10.9% 11.2% 11.3%

memo: Total Agency Spend in-month 262 358 448 1,002


3

Monthly WTE

As at June 2020 Jun-20 May-20 Jun-19 YTD

£000's £000's £000's £000's

Budgeted WTE in-month 4,026.9 4,048.1 3,852.3 12,042.0

Substantive Staff 3,811.0 3,751.2 3,433.6 11,275.3

Medical Agency Staff 16.3 18.7 11.8 57.0

Medical Locum Staff 27.7 18.4 18.3 72.5

Additional Medical Sessions 2.7 6.5 9.2 8.8

Nursing Agency Staff 11.7 9.9 27.6 46.0

Nursing Bank Staff 137.6 115.4 93.2 382.3

Other Agency Staff 8.5 10.0 12.3 32.2

Other Bank Staff 77.7 73.2 60.2 230.1

Overtime 36.4 51.4 49.6 117.8

On Call 8.4 5.1 6.9 19.1

Total Temporary WTE 327.0 308.7 289.1 965.7

Total WTE 4,137.9 4,059.9 3,722.7 12,241.0

Variance (F/(A)) (111.0) (11.8) 129.6 (199.0)

Temp. Staff WTE as % of Total WTE 7.9% 7.6% 7.8% 7.9%

memo: Total Agency WTE in-month 36.5 38.6 51.7 135.2

0100200300400500600700800900

1,000

£k

Rolling 14 month medical staff expenditure - additional sessions , locum and agency

Additional Medical Sessions Medical Locum Staff Medical Agency Staff

0

100

200

300

400

500

600

700

800

£k

Rolling 14 month nursing staff expenditure - bank and agency

Nursing Bank Staff Nursing Agency Staff


4

Balance Sheet

The cash at bank as at the end of June 2020 is £26.1m.

Cash flow forecast for the year compared to actual

STATEMENT OF FINANCIAL POSITION

As at Plan Plan YTD Actual at Variance YTD

1 April 2020 31 March 2021 30 June 2020 30 June 2020 30 June 2020

£000 £000 £000 £000 £000

Intangible assets 40,972 48,993 39,204 42,503 3,299

Property, plant and equipment 110,593 147,050 117,751 115,154 (2,597)

Trade and other receivables 5,707 5,707 5,707 5,707 0

Total non-current assets 157,272 201,750 162,662 163,364 702

Inventories 2,872 3,000 3,000 2,781 (219)

Trade and other receivables 32,342 20,666 20,666 20,972 306

Cash and cash equivalents 2,441 1,510 16,010 26,071 10,061

Total current assets 37,655 25,176 39,676 49,824 10,148

Trade and other payables (33,692) (23,000) (24,419) (28,911) (4,492)

Borrowing repayable within 1 year (58,529) (11,364) (58,249) (58,891) (642)

Current Provisions (67) (67) (67) (67) 0

Other liabilities (1,933) (1,000) (20,000) (24,026) (4,026)

Total current liabilities (94,221) (35,431) (102,735) (111,895) (9,160)

Total assets less current liabilities 100,706 191,495 99,603 101,293 1,690

Borrowings (52,538) (59,241) (53,814) (53,098) 716

Provisions (744) (744) (744) (741) 3

Total non-current liabilities (53,282) (59,985) (54,558) (53,839) 719

Total assets employed 47,424 131,510 45,045 47,454 2,409

Financed by

Public dividend capital 74,065 160,844 74,379 74,065 (314)

Revaluation reserve 6,942 6,942 6,942 6,942 0

Income and expenditure reserve (33,583) (36,276) (36,276) (33,553) 2,723

Total taxpayers' and others' equity 47,424 131,510 45,045 47,454 2,409

0

5,000

10,000

15,000

20,000

25,000

30,000

Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20

Actual (£'000) Plan (£000) Forecast (£'000)

Cash balance actual and forecast versus plan


5

Capital Progress Report

The initial capital budget for the year was approved at the Trust Board Meeting in January as part of the operational plan process. Following a request from NHSI a revised capital plan was prepared and submitted. The figures shown above reflect the changes. Overall the capital programme has a reduction of £1.1m as a result of the review. The Coronavirus pandemic has had a significant impact on the capital programme both in terms of the items on the capital programme and the timing. The ED scheme is to start later in the year and the capital programme reflects this change. The figures shown are as submitted to NHSI. The forecast is currently in line with the plan. Ecare figures have been updated to reflect the latest position following an initial review of the requirements.

Recommendation: To note the summary report.

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

Apr(actual)

May(actual)

Jun(actual)

Jul(forecast)

Aug(forecast)

Sep(forecast)

Oct(forecast)

Nov(forecast)

Dec(forecast)

Jan(forecast)

Feb(forecast)

Mar(forecast)

Capital Expenditure - Actual vs Plan 2020/21

Other Capital E Care ED Development Operational priorities Decant Ward Total Plan

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total

Actual Actual Actual Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast 2020-21

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

E Care 520 1,541 568 819 884 845 1,003 968 851 773 745 716 10,233

ED Development 0 16 0 0 100 200 500 1,000 1,500 2,000 2,300 1,500 9,116

Operational priorities 289 243 24 15 15 100 100 115 115 0 35 30 1,081

Decant ward 0 0 0 100 350 450 650 850 1,200 1,200 1,200 871 6,871

Other Schemes 558 590 1,431 2,525 1,394 2,462 2,546 2,338 2,421 1,989 1,357 726 20,337

Total / Forecast 1,367 2,390 2,023 3,459 2,743 4,057 4,799 5,271 6,087 5,962 5,637 3,843 47,638

Total Plan 2,562 1,632 2,546 2,430 3,151 5,113 3,799 3,734 3,945 7,063 7,053 4,608 47,636


13. New NED introduction (verbal)To receive an introductory presentationFor ReferencePresented by David Wilkes


14. Trust Improvement plan (enclosed)To note the reportFor DiscussionPresented by Sheila Childerhouse


Page 1.



SUBJECT: Trust improvement plan

AGENDA ITEM: Item 14

PREPARED BY: Sue Wilkinson, Executive Chief Nurse


FOR: Information

In order to ensure the Trust is able to effectively learn and improve from the CQC findings as well as other internal and external quality improvement findings a new improvement framework has been developed. The framework will be delivered through structured oversight and internal quality assurance monitoring by:

- Subject lead quality review meetings with the SRO Cluster Project Manager – these meetings are operational and provide review and challenge with an opportunity to update on progress

- Senior responsible office (SRO executive) cluster meetings – these meetings are operational and provide senior oversight and challenge as well as an appropriate escalation forum

- Improvement programme board – a Board-committee whose membership includes non-executives, executives and senior leaders from across the Trust as well as representation from the CCG.

The oversight and quality assurance framework ensures effective delivery of the agreed improvement actions to the defined timescales.

WSFT Board

SRO

improvement

cluster - A

SRO

improvement

cluster - B

SRO

improvement

cluster - C

SRO

improvement

cluster - D

SRO

improvement

cluster - E

Improvement Programme

Board (monthly)

Subject lead

quality review

meetings

Subject lead

quality review

meetings

Subject lead

quality review

meetings

Subject lead

quality review

meetings

Subject lead

quality review

meetings


Page 2.

- All plans are held centrally and updated by the PMO to ensure effective version

control - Any changes to plans are subject to Improvement Board approval. There are no

unilateral changes to plans outside of this change control process Through this framework the newly established Improvement Programme Board has met and reviewed the Trust’s improvement plan. The latest iteration of this plan was received and approved by the Board of Directors on 31 July 2020. To maintain transparency the plan is also available on the Trust website. Significant emphasis within the framework has been placed on testing the embeddedness of improvements using the status of action covering Red to Blue as described in the table below.

Status Description

Red Action beyond due date

Amber Action at risk of missing due date

Green Action on target for delivery by due date

Black Action implemented, assurance testing ongoing

Blue Action implemented and assurance evidence that action is embedded with agreed cycle of ongoing assurance

The responsibilities of the Improvement Programme Board include:

Receiving evidence and approving recommendations to change action status to “Black” (action implemented, assurance testing ongoing). This will need to include evidence of delivery across all relevant divisions

Receive evidence and approve recommendations to change action status to “Blue” (action implemented and assurance evidence that action is embedded with agreed cycle of ongoing assurance). This will need to include evidence of delivery across all relevant divisions

Approve the assurance cycle for actions with an agreed “Blue” status and receive evidence that this assurance model is being delivered

Approve changes to the assurance cycle for individual actions based on the assurance findings. This includes the ability to move an action back to active to further mitigate and improve delivery.

As this framework becomes embedded and action status moves from Black to Blue assurance findings to evidence that improvements are embedded within relevant services will be reported to the Board of Directors and summarised for the Council of Governors. Over the next reporting period it has been agreed to test this methodology by undertaking a ‘deep dive’ review with the CCG of the maternity actions rated as Black (Action implemented, assurance testing ongoing). Based on the findings these improvements may be moved to business as usual monitoring. Recommendation The Council of Governors are asked to note:

1. the report and updated improvement plan 2. that future reports will include a summary of assurance findings to evidence that

improvements are embedded within relevant services.


15. Pathology services (enclosed)To receive an updateFor ReferencePresented by Louisa Pepper


Page 1.



SUBJECT: Pathology services report


PREPARED BY: Nick Jenkins, Executive Medical Director

PRESENTED BY: Louisa Pepper, Non-executive Director

FOR: Information

Introduction

In April 2020, ESNEFT (East Suffolk & North East Essex NHS Foundation Trust) announced that the current NEESPS (North East Essex & Suffolk Pathology Service) networking arrangement with WSFT (West Suffolk NHS Foundation Trust) will cease no later than 31st October 2020. A joint working group has been set-up between ESNEFT and WSFT to oversee the transition and to work on finding an alternative solution to the current arrangements. This paper provides a summary of the work of the Joint Working Group and other pathology updates. A Pathology Transformation Lead has now been appointed to oversee the dissolution of the current networking arrangement and further develop the transformation of the pathology services. NEESPS Joint Working Group A number of sub-groups are progressing areas of responsibility:

HR - The agreed 45-day staff consultation commenced on 30th June 2020. A virtual launch was held for all affected employees. Feedback to date has been positive with employees taking up the offer of 1:1 sessions to discuss any concerns or answer any questions they may have. Discussions continue regarding data sharing and information on recruitment activity and vacancies.

Contracting - Work continues on reviewing the current list of contracts and what future alternative arrangements need to be considered. A proposal has been agreed to set aside the existing consortium agreement, a legacy document from TPP, which will allow ESNEFT and WSFT to create a new legal agreement as to the future networking arrangements. Discussions continue regarding: community pathology; community phlebotomy; and transition of Public Health England (PHE) services.

Finance Sub-group – A number of work streams are being undertaken to ensure effective: transition of pay budgets; review of non-pay and supplier expenditure; and income analysis to ensure accurate forecasting. A draft financial principles paper has been issued by WSFT to ESNEFT for comment and discussion.


Page 2.

ICT Sub-group - the sub-group is currently working through each system to ascertain what the current service offering is, the WSFT requirement; both initially after 31.10.2020 and in the longer term and any interdependencies. The contracting group can then align contracts accordingly. ESNEFT are pulling together proposals for information and communication technology (ICT) support to WSFT with costings for WSFT consideration. Exploration of the options for the laboratory information management system (LIMS) and Quality Management System (QMS) are continuing.

Business information (BI) Sub-group - The group assessing the current roles, responsibilities, how they will transfer to WSFT and what capacity constraints there may be. They are considering the complexities of data submission with the dissolution date falling mid-financial year.

Clinical Sub-Group - The Pathology Transformation Manager is aligning how current clinical business as usual is unaffected by the dissolution and how robust and stringent governance will continue. In light of continuing networking in some areas WSFT are also designing how ongoing clinical governance between ESNEFT and WSFT may look.

Identified Opportunities for Transformation A range of initiatives are being considered to ensure future service sustainability and transformation. All clinical disciplines have been approached to consider all viable networking opportunities. Clinical leads are being strongly encouraged to develop options appraisals for all possible networking arrangements at discipline level; to include existing public and private opportunities, examples of good practice from within and outside the UK and lessons learnt. This data will be collated, pathology wide synergies identified where possible and discussions will be held with proposed network partners to establish the way forward for the opportunities identified. The Pathology Transformation Manager is leading on this to ensure clinically led, innovative consideration is given to the future. It is important that WSFT seizes this opportunity to innovate, utilising all networks available to us, looking outside of traditional models and pushing forward using our GDE status to work at pace towards the adoption of a true digital pathology service. A WSFT pathology staff engagement event is proposed for September 2020 to ask for employee input into as to how they see the future of the pathology service. Recommendation The Council of Governors are asked to note the report and progress being made.


16. Annual Report & Accounts 2019/20(on Trust website or hard copy onrequest)To receive the Annual Report & Accountsfor 2019/20https://www.wsh.nhs.uk/Corporate-information/Information-we-publish/Annual-reports.aspxFor ReferencePresented by Richard Jones




SUBJECT: Governor issues

AGENDA ITEM: 15

PREPARED BY: Richard Jones, Trust Secretary & Head of Governance

PRESENTED BY: Richard Jones, Trust Secretary & Head of Governance

FOR: Information

The Council of Governors is asked to receive the annual report and accounts in public session. The report was approved by the Board in closed session in June but could not be reported publically until it had been laid before Parliament – this took place on 6 June 2020. The full document is available via the link below: https://www.wsh.nhs.uk/Corporate-information/Information-we-publish/Annual-reports.aspx The intention is still to hold an annual members meeting in September but using MS Teams in order to comply with social distancing requirements. Further details are being finalised but the format will be based on the Chair and Chief Executive providing an introduction followed by a session on COVID-19 response and recovery.

Recommendation: To receive the annual report and accounts.



17. Annual Audit Letter (enclosed)To receive the report from BDO, ExternalAuditorsFor ReferencePresented by Matthew Weller


WEST SUFFOLK NHS

FOUNDATION TRUSTAnnual Audit Letter

Year ended 31 March 2020

Item 17


2 | BDO LLPWest Suffolk NHS Foundation Trust – Annual Audit Letter for the year ended 31 March 2020

EXECUTIVE SUMMARYINTRODUCTION

Purpose of the Annual Audit Letter

This Annual Audit Letter summarises the key issues arising from the work

that we have carried out in respect of the year ended 31 March 2020.

It is addressed to the Trust but is also intended to communicate the key

findings we have identified to key external stakeholders and members of

the public.

Responsibilities of auditors and the Trust

It is the responsibility of the Trust to ensure that proper arrangements are

in place for the conduct of its business and that public money is

safeguarded and properly accounted for.

Our responsibility is to plan and carry out an audit that meets the

requirements of the National Audit Office’s (NAO’s) Code of Audit Practice

(the Code). Under the Code, we are required to review and report on:

• The financial statements and auditable parts of the remuneration and

staff report;

• Whether the Trust has made proper arrangements for securing economy,

efficiency and effectiveness in its use of resources.

We are also required to review and report on the Annual Report, Annual

Governance Statement and the Trust Accounts Consolidation schedules.

BDO LLP

20 July 2020

Audit conclusions

We recognise the value of your co-operation and support

and would like to take this opportunity to express our

appreciation for the assistance and co-operation provided

during the audit.

Audit area Conclusion

Financial statements Unqualified opinion

Use of resources Qualified ‘except for’ opinion in

respect of the Trust’s

arrangements for securing

economy, efficiency and

effectiveness

Trust accounts

consolidation

schedules

Consistent with the financial

statements

NAO group assurance

review

No exceptions reported

Annual Report Not inconsistent or misleading

with the financial statements

Annual Governance

statement

Compliant with NHS

Improvement’s guidance

Remuneration and

staff report

Auditable parts found to be

properly prepared



FINANCIAL STATEMENTS

Audit conclusion

We issued an unqualified audit opinion on the financial statements.

This means that we consider that the financial statements give a

true and fair view of the financial position and its net expenditure

for the year.

An emphasis of matter has been raised in respect of the valuation of

land and buildings due to a material uncertainty included in the

valuation report by the Trust’s valuer and disclosed by the Trust in

Note 12.4.

20209

MATERIALITY

£5.03 million

CLEARLY TRIVIAL

£200,000

10%

Unadjusted differences vs.

materiality

Final materiality

Materiality was calculated at £5.03 million based on a benchmark of

1.75% of gross expenditure.

Material misstatements

We did not identify any material misstatements.

Unadjusted audit differences

We identified current year audit differences that, if posted, would

decrease the deficit for the year by £481,000.

We reported these audit differences and the Audit Committee

confirmed that as the impact was not material, the final published

financial statements would not require amendment.




We set out below the risks that had the greatest effect on our audit strategy, the allocation of resources in the audit, and the direction of

the efforts of the audit team.

Risk description How the risk was addressed by our audit Results

Management

override of controls

Auditing standards

presume that

management is in a

unique position to

perpetrate fraud by

overriding controls

We carried out the following planned audit

procedures:

• Reviewed and verified journal entries made

in the year, agreeing the journals to

supporting documentation. We determined

key risk characteristics to filter the

population of journals. We used our IT team

to assist with the journal extraction;

• Reviewed estimates and judgements applied

by management in the financial statements to

assess their appropriateness and the

existence of any systematic bias; and

• Reviewed unadjusted audit differences for

indications of bias or deliberate

misstatement, or where they appear to be

solely to deliver the Trust’s agreed control

account total in order to receive Provider

Sustainability Funding.

Our audit of journals did not identify any management override

of controls in preparing the financial statements.

We reviewed significant estimates made by management in

preparing the financial statements and found no evidence of

deliberate bias in management estimates.

We did not identify any evidence to suggest unadjusted audit

differences are indicative of bias or deliberate misstatement by

management.





Revenue recognition

Auditing standards

presume that income

recognition presents

a fraud risk.


procedures:

• Updated our understanding of the Trust’s

internal control environment for the

significant income streams, including how this

operated to prevent loss of income;

• Reviewed the outturn contract income

against service level agreements for key NHS

commissioners and reconciliations of outturn

activity with management estimates of

forecast final outturn contract income; and

• Reviewed the process for resolving

discrepancies between the Trust and NHS

commissioners through the agreement of

balances process and the rationale behind

management’s estimate of amounts

receivable where there were contract

disputes.

Our testing did not identify any issues in respect of revenue

recognition. There were some non-trivial differences noted

between the Trust’s reported position for NHS income and the

counter-party reported expenditure that we investigated and

were satisfied that the Trust has reported balances and

transactions accurately in its financial statements.





Expenditure cut-off

In public sector

bodies there is a risk

of fraud related to

expenditure.


procedures:

• Checked that expenditure is recognised in the

correct accounting period by substantively

testing an increased sample of NHS and non-

NHS expenditure around year-end.

Our testing did not identify any issues in respect of expenditure

cut-off.

Valuation of land

and buildings

The valuation of land

and buildings is a

significant risk as it

involves a high

degree of estimation

uncertainty.


procedures:

• Reviewed the instructions provided to the

valuer and the valuer’s skills and expertise in

order to determine if we could rely on the

management expert;

• Confirmed that the basis of valuation for

assets valued in year was appropriate based

on their usage;

• Reviewed the accuracy and completeness of

information provided to the valuer, such as

floor areas;

• Reviewed assumptions used by the valuer,

and movements against relevant indices; and

• Followed up valuation movements that

appeared unusual.

We confirmed that the property valuations are materially correct

and the basis of valuation for assets valued in the year is

appropriate.

We confirmed that the source data provided to the valuer was in

line with our expectations.

We concluded that we were able to rely on the valuer (who is

considered to be a “management expert”).

We noted that the Trust had incorrectly recorded a capital

addition as a capital receivable as at 31 March 2019, thus

overstating the value of receivables by £481,000.

Due to the revaluation exercise performed, the value of

property, plant and equipment as at 31 March 2019 was correct

with the impact of this error being that the valuation decrease

recorded in 2018/19 was understated by £481,000.

The Trust has adjusted for this misstatement during the 2019/20

financial year, and as such, the 2019/20 valuation decrease is

overstated by £481,000. This error has no impact on the

cumulative position of the revaluation reserve.



USE OF RESOURCES

Audit conclusion

We issued a qualified ‘except for’ use of resources conclusion, referring to the weaknesses in proper arrangements for securing economy,

efficiency and effectiveness in respect of the Trust’s use of resources.

We set out below the risks that had the greatest effect on our audit strategy.


Sustainable finances

Per the month 7 Board

report, the Trust was

forecasting a £15.7

million deficit in

2019/20, a deterioration

in financial performance

compared to the original

forecast breakeven

position.


procedures:

• Reviewed the Trust’s in year budget monitoring

processes, and the completeness and accuracy of

management information reported for decision

making purposes.

• Reviewed the Trust’s medium term financial plan

and annual budgets, including the reasonableness of

the underlying assumptions made by management

and the consideration of risks to sustainable

deployment of resources.

• Reviewed progress against the Trust’s CIP savings

targets and arrangements to ensure that future

targets are realistic and achievable, including how

the Trust works with commissioners and other third

parties to develop required savings schemes.

We found that:

• The Trust set an original budget for 2019/20 of a

£10.2m deficit. If achieved, the Trust would receive

Provider Sustainability Funding (PSF), Financial

Recovery Funding (FRF) and a Marginal Rate

Emergency Tariff (MRET) totalling £10.2m, bringing

the Trust to an overall breakeven position. After

excluding an impairment of PPE of £7.9m (which

was not expected but is allowed to be excluded

from financial performance measures), the net

effect of capital grants and donations of £105,000,

and PSF relating to 2018/19, but not awarded until

2019/20 of £280,000, the Trust achieved a surplus

of £102,000, thus improving on the forecast by

£102,000. The final outturn for 2019/20 was a

deficit of £7.6m, increasing the cumulative deficit

to £33.6m (2018/19: £31.3m), after allowing for a

transfer to the revaluation reserve and the transfer

by absorption of Newmarket Hospital.

• During 2019/20, the Trust delivered all of the £8.9m

CIP, which played a significant part in the Trust

achieving its overall financial plan.



USE OF RESOURCES

Risk description Results

Sustainable finances (continued) (continued from page above)

• The final underlying deficit achieved of £10.4m (after excluding PSF, FRF, MRET and impairments) is an

improvement on the prior period equivalent deficit of £13.1m (excluding PSF and impairments). There

was also an improvement in operating profitability, achieving an operating deficit of £4.2m compared

to an operating deficit of £9.5m in 2018/19.

• The planned deficit control total set by NHSI for 2020/21 is £8.9m. If achieved, this would give the

Trust access to £8.9m of additional funding, achieving a breakeven position. Delivery of the Trust’s

current 2020/21 plan requires a further £8.7m of CIP savings, which is less than the £9.1m delivered in

2019/20, but nonetheless still a significant challenge.

• Given the current coronavirus pandemic, the Trust is receiving top-up funding which has not

historically been received and was not included within this budget. This will be received in the months

of April 2020 to July 2020, with an expectation that it will remain in place until October 2020.

• Although a breakeven for 2019/20 would be a notably positive achievement, there would remain

significant cumulative deficits and borrowing levels to address. As at 31 March 2020, the Trust has

£111.1m of borrowing, of which £58.5m is required to be repaid in 2020/21. £46.6m of this balance is

planned to be converted into Public Dividend Capital (PDC) and therefore the Department of Health

and Social Care (DHSC) will provide the cash to repay this borrowing through issuing PDC. This still

leaves £11.9m of other borrowing requiring repayment in 2020/21, which would have a significant

impact on cash reserves if paid and is likely to require further (replacement) borrowings to be taken

out. The Trust also has a significant capital programme planned for 2020/21 and beyond, which

requires £8.5m of cash per the operational plan, with the funding for a further £23.8m of the

programme currently unidentified. It is therefore likely that further borrowings will be required in the

future.

• Notwithstanding the achievements in 2019/20 and the planned breakeven after FRF and MRET for

2020/21, there remain significant issues to be addressed in terms of cumulative deficits, borrowing and

cash flows.

We therefore concluded that there is insufficient evidence that the Trust’s arrangements support, in all

significant respects, its ability to achieve planned and sustainable financial stability and modified our

opinion in this respect.



REPORTS ISSUED AND FEES

Fees summary

2019/20

£

2018/19

£

Audit fee

Trust financial statements and use of resources 45,225 45,225

Non-audit assurance services

Fees for audit related services

Quality Report 45 4,295

Total fees 45,270 49,520

Our fee for non-audit assurance services has

been adjusted to reflect that there was no

requirement for a Quality Report audit in

2019/20. The fee stated represents a

recharge for the costs incurred by BDO on

this assurance service before the

requirement was removed.

Reports Date To whom

Audit planning report January 2020 Audit Committee

Audit progress report April 2020 Audit Committee

Audit completion report June 2020 Audit Committee

Annual audit letter July 2020 Audit Committee

Communication


FOR MORE INFORMATION: The matters raised in our report prepared in connection with the audit are those we

believe should be brought to your attention. They do not purport to be a complete record

of all matters arising. This report is prepared solely for the use of the company and may

not be quoted nor copied without our prior written consent. No responsibility to any third

party is accepted.

BDO is an award winning UK member firm of BDO International, the world’s fifth largest

accountancy network, with more than 1,000 offices in more than 100 countries.

BDO LLP is a corporate establishment under the Limited Liability Partnership Act 2000 and

a UK Member Firm of BDO International. BDO Northern Ireland, a separate partnership,

operates under a licence agreement. BDO LLP and BDO Northern Ireland are both

separately authorised and regulated by the Financial Conduct Authority to conduct

investment business.

© 2020 BDO LLP. All rights reserved.

www.bdo.co.uk

Rachel Brittain

t: 020 7893 2362

e: [email protected]


18. Report on constitutional changes(enclosed)To note the report.For ReferencePresented by Richard Jones


Page 1.



SUBJECT: Report on constitutional changes


PRESENTED BY: Richard Jones, Trust Secretary & Head of Governance

FOR: Information

At the Council of Governors meeting on 6 May 2020 a process to amend the constitution to enable electronic communication by the Council of Governors to support quoracy and decision-making (voting) was agreed. The following motion and ballot was therefore emailed to governors: The Motion: To approve the Proposed Amendments to Annex 7 (Standing Orders for the Practice and Procedure of the Council of Governors) of the Trust’s Constitution to allow the Governors at the discretion of the Chairman to: (1) attend meetings of the Council of Governors by electronic communication methods; (2) vote and make decisions where not physically present at a meeting (electronically by e-mail voting or by postal voting); and (3) pass written resolutions. Email ballot: Governors were asked to submit their vote by replying to the email and indicating their vote with respect to the Motion.

Result of ballot: 20 governors voted in favour 1 governor voted in favour but beyond the deadline 4 governors did not vote Along with the Council of Governors ballot the proposed changes were presented to and approved by the Trust Board on 29 May and the constitution has subsequently been amended to reflect these changes.


19. Report from Nominations Committee(enclosed)To note a report from the NominationsCommittee meeting of 25 June 2020For ReferencePresented by Sheila Childerhouse




SUBJECT: Report from Nominations Committee meeting held on 25 June 2020

AGENDA ITEM: 19


FOR: Information

This report summarises discussions that took place at the Nominations Committee meeting on 25 June 2020.

The feedback summary of the 360° appraisal reports for the NEDs were reviewed and discussed. Emergent themes from stakeholder assessments, areas of strength and opportunities to increase impact and effectiveness were agreed for discussion at their appraisal meetings.

The terms of office for the NEDs were reviewed. The committee considered the reappointment of two NEDs who were approaching the end of their term of office and made recommendations to the closed session of the Council of Governors meeting on 11 August 2020.


20. Report from Engagement Committee(enclosed)To receive the minutes from the meetingof 21 July 2020For ReferencePresented by Florence Bevan




SUBJECT: Report from Engagement Committee, 21 July 2020

AGENDA ITEM: 20

PREPARED BY: Georgina Holmes, FT Office Manager

PRESENTED BY: Florence Bevan, Governor

FOR: Information and Review

BACKGROUND This attached minutes (annex A) provide a summary of discussions that took place at the Engagement committee meeting on 21 July 2020. This included feedback from a workshop on the results of the inpatient survey for 2019 which was attended by members of the Patient and Carers Experience Group, where attendees brainstormed ideas, some of which governors may be able to be involved in in the future, (appended to minutes). . RECOMMENDATION The Council of Governors is asked to note the minutes of the meeting of 21 July 2020.


DRAFT

MINUTES OF THE COUNCIL OF GOVERNORS ENGAGEMENT COMMITTEE

HELD ON TUESDAY 21 JULY 2020, 4.30pm

Via Microsoft Teams

COMMITTEE MEMBERS Attendance Apologies

Peter Alder Public Governor

Florence Bevan Public Governor

June Carpenter Public Governor

Peta Cook Staff Governor

Jayne Gilbert Public Governor (from agenda item 5)

Gordon McKay Public Governor

Liz Steele Public Governor (Lead Governor)

In attendance

Georgina Holmes FT Office Manager

Richard Jones Trust Secretary / Head of Governance

Cassia Nice Head of Patient Experience

Kirsty Rawlings Outpatients & Health Records Manager (agenda item 3)

Action 20/19 APOLOGIES

There were no apologies for absence.

20/20 MINUTES OF MEETING HELD ON 21 APRIL 2020 The minutes of the above meeting were agreed as a true and accurate record.

Ref 20/13, Engagement Strategy, it was noted that the lack of opportunity for face to face contact meant that engagement with members and the public was likely to be different in the future, therefore digital communication would need to improve /increase.

20/21 MATTERS ARISING ACTION SHEET The actions were reviewed and the following issues raised: Item 35, Diabetes talk at Haverhill. It was currently not possible to make any plans for this to take place. In future consider videoing presentation, as the Trust would need to think differently about public engagement. The Annual Members Meeting (AMM) would be in the format of a Teams meeting, recognising that there might be issues for some people in accessing this. People did not need to have the Teams app to access this and it was not necessary to be able to see everyone who was attending the meeting, except the presenter. An FT newsletter would be sent out in the next couple of weeks including that information about the AMM which could be found on the website. Item 38, Follow-up with Helen Beck whether it was necessary to include all enclosures again when sending a letter about a rearranged appointment. Kirsty Rawlings explained the process for generating letters via e-Care to Synertec who then sent out the letter with relevant enclosures. If an appointment was re-scheduled Synertec treated this as a new appointment and included all the enclosures again.

`


DRAFT

2

A large number of comments had been received in relation to this it was recognised that this was a considerable waste and cost. The team had looked at a number of ways to address but to date a solution had not been found. Synertec recognised when an appointment was a follow-up appointment and therefore did not include the enclosures again.

Q

A

If Synertec could identify a follow-up appointment was it possible for it to identify a re-scheduled appointment? This might be possible and would be discussed with the team. Action: look at whether it was possible for the system to identify re-arranged appointments in the same way as it could follow-up appointments.

K Rawlings

Q

A

Confusion was caused with cancellation of appointment letters being received on the same day as follow-up appointment letters, which meant that patients had to call the hospital to clarify when when/if their appointment was taking place. This would be followed up. Action: feedback on issue with cancellation and re-arranged appointment letters being received on the same day. It was noted that more patients were using the patient portal which would help to reduce printing and postage costs.

K Rawlings

20/22 EXPERIENCE OF CARE Cassia Nice gave an update what the patient experience team had been focussing on during COVID.

Most engagement activities had been paused and number of PALs enquiries and complaints had been very low which meant that the team had been able to focus on other areas.

The patient experience team was now fully staffed. A new complaints manager had been appointed who was working to reduce the backlog of outstanding complaints and the key performance indicator for this was now green.

Q A

What proportion of complaints were closed through the first response? The majority of complaints were closed with the first response, often through face to face meetings or through zoom calls. Action: provided first response rate for closure of complaints.

C Nice

During COVID the team had focussed on communication and additional staff had been seconded into the team to enable the Trust to provide a seven day week, 8.00am to 8.00pm service. A live webchat had been introduced and it was hoped to continue this indefinitely.

A relative liaison help line had also been set up which was managed by shielding nurses, therapists and several consultants, all of whom had access to e-Care and received calls from relatives about patients in the hospital. This service was very popular and very positive feedback had been received. Staff had enjoyed being part of this team and found it very rewarding as they were able to contribute and help people while they were shielding.

There were originally 25 members of staff in the team and on the busiest day they received over 300 calls, today they had received 188 calls.


DRAFT

3

This was another example of the benefits of e-Care and members of the team had the time to talk to relatives and answer their questions. They had also identified a number of vulnerable people in the community had been able to arrange for them to be visited by carers. The Trust was looking to see how this could continue in the future as shielding staff returned to work.

Q A

Could volunteers be used for this service? It would not be appropriate to use volunteers as this required clinical staff/knowledge to provide information to relatives.

A Keeping in Touch video call service had also been set up to enable patients and relatives to keep in touch face to face. This had been very successful and would continue for the future.

There was also a need to understand how patients would feel about not having face to face appointments in the future. Over the coming weeks the team would be receiving feedback on people’s experiences as they come back into the hospital and this may provide some ideas for future governor engagement.

One possibility for governor engagement was with patients about the postponement of elective procedures. It was noted that a lot of these people were in pain and this was having an effect on their daily lives. It was important to keep people informed as much as possible and it was suggested that the Trust could put a short video on its website to explain what was happening and how long people might have to wait.

Action: presentation to Patient Experience committee to be circulated to Engagement Committee members.

C Nice / G Holmes

20/23

REVIEW OF ENGAGEMENT PLAN The Engagement plan was reviewed and the following noted:

Governors to provide input/suggestions for FT Newsletter

The regional lead governor group was continuing to meet virtually which had been useful for sharing information on how/if other Trusts were engaging with the public during COVID.

If governors undertook any engagement activities in the hospital, eg quality walkabouts, they would need to complete a risk assessment in the same way as staff were required to. This was to protect governors as well as patients.

20/24

24.1

24.2

FEEDBACK REPORTS Membership numbers The membership numbers were reviewed and it was noted that the total was ahead of target, ie 6252 vs 6000. Report from Patient and Carers Experience Group The most recent meeting of this group had been a workshop on the inpatient survey for 2019 where attendees brainstormed ideas, some of which governors may be able to be involved in in the future. A copy of these are appended to these minutes (Appendix A).

20/25 ISSUES FOR ESCALATION TO THE COUNCIL OF GOVERNORS There were no issues for escalation to the Council of Governors.


DRAFT

4

20/26 DATES OF MEETINGS FOR 2020 Tuesday 20 October 4.30-6.00pm


DRAFT

5

Appendix A

Picker inpatient survey 2019 early results

Q14 Were you ever bothered by noise at night from other patients?

What impacts on this that is within your influence?

Routine, offer patients to turn down lighting then offer hot drink and if necessary offer sleeping

tablets.(2)

Advise patients to put phones on to silent as well as turn down TV.

Turn patient buzzer volume down.

Screensavers with a message “Please be quiet as patients are sleeping”.

Offering ear plugs as a last resort.(3)

Staff to get in touch with nurses who specialise in Dementia to resolve situations.

Look to move dementia patient to side room if appropriate.

Reduce moving or admitting patients at night time.(2)

Answering call bell in a timely manner.

Increase volunteer support

What impacts this not within your influence?

Patients with dementia (3)

Patients who smoke leaving the wards.

Patients who talk between themselves.

Resources, not enough side rooms in wards.

Human factors.

Recreation/ activity room.

What are you going to take back to your area as a result?

Staff who are not busy can sit with unsettled patients to put them as ease.(2)

To inform staff problems that may occur so the team is prepared before they start.

Communicate with staff of patients routines to prevent a disruption.

Remind staff to minimise movement at night.

Q70 During your hospital stay, were you ever asked to give your views on the quality of your

care?


A+E department to provide paper copy on admission.

Ask for improvement to text messaging service.

Satisfaction questioners on discharged patients.

Communication with PALS on information that may be useful.

To put in place a suggestion box for patients(2)

Create a survey questionnaire to discharger summaries.

Ensure patient surveys are completed by patients who are able to feed back.

Providing targets to staff to meet completion of surveys in time.


DRAFT

6


Resources and spending.

Not enough volunteers to support the service.(2)

Training in Meridian.

Messaging service that’s sent to patients.


To put forward to have more volunteers in the department of subject.

To improve regular communication to patients as well as to support volunteers to communicate with

the patient.

Discharge issues: Q60 Did a member of staff tell you about any danger signals you should watch for after you went home? Q61 Did hospital staff take your family or home situation into account when planning your discharge? Q62 Did the doctors or nurses give your family, friends or carers all the information they needed to help care for you? Q58 Did a member of staff tell you about medication side effects to watch for when you went home?


Symptoms to look out for in patients before they go home.

Inform patients of common side effects so the patient is fully informed.

Ensure patients have access to contact details to the pharmacy so patients. can require more

information on certain medication.

Access for families to discharge co-ordinator.

On admission establish home situation and support in place.

Discussion with family members if patient consents.


Not having a pharmacist to talk to all patients getting polypharmacy/time constraints discharged

knowledge/ counselling for all.

Overload of information.

Funding for pharmacist/ technician.

Unrealistic expectations.


DRAFT

7


Put forward for Patient and staff education.

To keep building on communication between families/patients/care home/care agency.

Put forward for extra support/ process change and staff education.

Availability of pharmacy information leaflets.

Q18 If you brought your own medication with you to hospital, were you able to take it when you needed to?


Giving patients support in educating them on self-managing.(2)

Empowering nurses to allow their patient to have independence.(2)

Providing clear communication to patient if there are any changes to medication.

Any changes made to medication to have an accurate documentation on e-care.

Assessing patient capacity.


Does the Hospital have a self-medication policy.

Pharmacy support.

More nurse prescribers.

Patient honesty.

Medical/Clinical condition.

Patient safety including other patients on the ward (unable to leave medication unlocked).


To build communication with patients to find out what medication they are taking and a reason for

taking the medication.

To have clear policies put in place for patients and staff then to follow up with audits to make sure the

policies are followed.

Q6 How do you feel about the length of time you were on the waiting list before your admission to hospital? Q9 From the time you arrived at the hospital, did you feel that you had to wait a long time to get a bed on a ward?


Plan discharge as soon as possible on admission.

Ensure patients are sent to DWA (Discharge waiting area) where appropriate.

Highlight (Golden Patient)

Organise TTO’s (To take out) transport in advance when a date is known to prevent any delay.


DRAFT

8


Patient flow outside of the ward, Social services/ External beds(CAB Delirium beds).

Awaiting funding or care packages.

Availability of specialist consultants.

ITU (Intensive care unit) capacity.

Managing expectations given to patient from GP.


Increase awareness of good communication.

To ensure available bed space by assessing beds in our area.

Plan for number of admissions in advance to prevent delays.

Q33 Sometimes in a hospital, a member of staff will say one thing and another will say something

quite different. Did this happen to you?


Improve awareness of different roles of staff.

Staff being prepared before conversations with patients.

Implement one to one with a Dr and nurse following ward round to update on current plans.

Ward manager nurse in charge to have an update from each nurse following handover.

Good communication equals good team.

Making sure there is clear documentation especially with following policies and protocols.


Control of members of staff and access to notes.

Short staffed as well as having a high turnover of staff.

When patients are getting transported to different wards.

Delegation.

Skill mix.

The view the patient may have on what they have been told.

Work load.


To drive communication between all staff.

Nursing staff to ensure patients understanding of information.


21. Lead Governor report (enclosed)To receive a report from the LeadGovernor.For ReferencePresented by Liz Steele




SUBJECT: Report from Lead Governor

AGENDA ITEM: 21

PRESENTED BY: Liz Steele, Lead Governor

FOR: Information

Since the last Council of Governors meeting I have continued to meet on a monthly basis with Sheila and Florence. This has provided us with the opportunity of raising some of the issues mentioned by governors in their emails. The pandemic has meant that no face to face meetings can take place, although our most recent meeting on 4th August 2020 will be held in Quince House in a suitably distanced environment. I was happy to be part of the interview process to select a new NED This took place via Teams and lasted all day. We had 5 candidates; in between each interview we had a few minutes break before starting again. At the end of the day we selected one NED and potentially an Associate NED I have also continued to make contact with other Lead Governors in the Eastern Region. The main topic of conversation is the challenges of the pandemic, video meetings, elections. I have had the following meetings: Thursday 21st May Informal NEDS/Governors meeting Friday 29th May Board Meeting Tuesday 9th June Florence and I met with Sheila Thursday 11th June Shortlisting meeting for NED position Thursday 25th June Nominations Committee meeting Thursday 25th June Informal Governor/NEDs meeting Friday 26th June Board Meeting Thursday 2nd July NED Interviews Wednesday 8th July Sheila’s Appraisal Friday 10th July Interview for S.E.G Independent Chair. Tuesday 14th July Florence and I meet with Sheila Tuesday 21st July Engagement meeting Thursday 23rd July Staff Governor Meeting. We have had regular email updates from Sheila and several governors have submitted questions to our Governor email address, with a summary being sent to all governors on a monthly basis. There may be opportunities soon to begin Quality Walk about but this is still being worked out. I expect more will be discussed at our meeting.


22. Staff Governors report (verbal)To receive a report from the StaffGovernorsFor ReferencePresented by Peta Cook




SUBJECT: Report from Staff Governors

AGENDA ITEM: 22

PRESENTED BY: Peta Cook, Staff Governor

FOR: Information

Issues raised by staff governors were reviewed at the recent quarterly staff governor meeting which was attended by Peta Cook, Amanda Keighley, Richard Jones, Georgina Holmes, Jeremy Over and Liz Steele.

Discussions were taking place about resuming Quality Walkabouts which NEDs and governors

would be invited to take part in if they felt comfortable with coming back into the hospital. A

set of principles and a process had been produced for volunteers which included consideration

of the locations they visited in and their own health. It was proposed that governors who

wished to take part in any activities within the hospital should be asked to go through the same

process as volunteers

.

Currently the best way for NEDs to engage with the community was to join virtual meetings.

NEDS and executive team members had joined Team handovers in adult services which had

been well received. The paediatric team had also offered a date for NEDs to attend a Teams

meeting but no response had been received. Currently the majority of these meetings were

training based but there could be further opportunities in September. Attending these would

help the NEDs understand conversations around ‘What Matters to You’. Dates for future

opportunities would be circulated to the NEDs.

Feedback from adult services: lone workers were finding it particularly challenging during

COVID as they were missing the daily face to face handover meetings/ discussions etc. Jeremy

Over explained that issues facing community staff were discussed at every weekly workforce

and staff support meeting. The Trust was actively promoting the clinical psychological support

service and staff who had taken advantage of this had found it very beneficial. It was stressed

that this was for everyday issues and staff should be encouraged to seek support sooner rather

than later. This service was being expanded so that it could support the long-term impact on

staff.

It was suggested that a case study from this service should be published in the Green Sheet to help staff understand the benefits of this service.

Feedback from paediatric services: currently a large number of staff were working from home and clinics were being used for other activities. Staff were now being encouraged to come into bases on a rota basis so that they got used coming in again and the change in practices, eg cleaning of equipment etc, as some were lacking confidence in returning. This was part of the workforce being supported in coming back into work.


PPE would be a challenge moving forward, particularly when visiting different schools etc, and everything was much more time consuming. There was a very large backlog in community paediatrics and a lot of work was being done on Visionable, one of the positives of which was that staff were able to communicate with parents more. The WSFT IT department had been very supportive of the community team and this had been

commented on by a number of staff. This had been particularly helpful with Visionable and

Moodle, an online training package, which would provide a lot more flexibility. Virtual video

appointments via Visionable still needed to be improved to make it easier for both parents and

therapists.

The importance of staff wellbeing was discussed and Liz Steele gave an example of the cathedral holding coffee sessions and sherry sessions via Zoom to help people feel included and supported.


23. Annual external audit review(enclosed)To receive a report and recommendationfrom the Audit Committee on the Trust’sExternal Auditors BDOFor ReferencePresented by Angus Eaton


Council of Governors – 11 August 2020

Executive summary: The NHS Foundation Trust Code of Governance document, issued by NHS Improvement, includes guidance to the Council of Governors relating to assessing the performance of the external auditors:

C.3.4. The Audit Committee should make a report to the Council of Governors in relation to the performance of the External Auditor, including details such as the quality and value of the work and the timeliness of reporting and fees, to enable to Council of Governors to consider whether or not to re-appoint them. The Audit Committee should also make recommendations to the Council of Governors about the appointment, re-appointment and removal of the external auditor and approve the remuneration and terms of engagement of the External Auditor.”

The attached draft report to the Council of Governors outlines the External Auditors performance for the 2019/20 financial year and recommends the continued use of BDO as External Audit provider.

The Audit Committee agreed this report at its meeting on 31 July 2020.

Trust priorities

Deliver for today Invest in quality, staff and clinical leadership

Build a joined-up future

Trust ambitions [Please indicate ambitions relevant to the subject of the report]

Previously considered by:

N/A

Risk and assurance:

BDO is subject to review by the Financial Reporting Council. No issues have been noted from the reviews completed.

Agenda item: 23

Presented by: Angus Eaton, Non-executive Director

Prepared by: Liana Nicholson, Assistant Director of Finance

Date prepared: 31 July 2020

Subject: External Audit report to Governors from the Audit Committee

Purpose: For information For approval

Deliver

personal care

Deliver

safe care

Deliver

joined-up care

Support

a healthy start

Support a healthy

life

Support ageing

well

Support all our staff


1

Legislation, regulatory, equality, diversity and dignity implications

International Standards of Auditing

Recommendation: The Council of Governors is asked to consider the feedback from the Audit Committee on the performance of the Trust’s External Auditors. This should provide sufficient assurance to the Council of Governors that BDO has provided a quality, timely and cost effective external audit service. The Audit Committee recommends that BDO should remain in appointment as the Trust’s External Auditors. The current contract with BDO expires on 31 March 2021, however the Audit Committee recommends that a direct award contract is given for 1 further year (covering 2021/22). After this a re-tendering exercise will be undertaken (starting July 2021).


2

1. Background

The NHS Foundation Trust Code of Governance document, issued by NHS Improvement, includes guidance to the Council of Governors relating to assessing the performance of the external auditors: C.3.4. The Audit Committee should make a report to the Council of Governors in relation to the performance of the External Auditor, including details such as the quality and value of the work and the timeliness of reporting and fees, to enable to Council of Governors to consider whether or not to re-appoint them. The Audit Committee should also make recommendations to the Council of Governors about the appointment, re-appointment and removal of the external auditor and approve the remuneration and terms of engagement of the External Auditor.”

2. Performance of the External Auditors

The Audit Committee met on the 31 July 2020, at this meeting the performance of the Trust’s external auditors was considered, in particular the: • Timeliness of reporting • Quality of work • Audit fees

2.1. Timeliness of reporting

The Audit Committee agreed that the Trust had a good working relationship with BDO and deadlines were always met. BDO responded to queries raised in 2019/20 promptly. Audit Reports have always been received to enable the Trust to meet the Annual Report and Accounts external filing deadlines. 2.2. Quality of Work

The Audit Committee considers that it has received good quality reports from BDO that communicate any significant findings arising from their audit. The reports have been helpful in assisting the Audit Committee in discharging its governance duties. They work effectively with Internal Audit ensuring that sharing of information provides a cost effective method of ensuring all audit requirements and risks can be met. Access to senior members of the Audit Team has been satisfactory during 2019/20. There was a change to the Responsible Individual (RI) during 2019/20 to ensure independence remained with the Trust, and this was a seamless transition. The Audit Committee also takes comfort on how BDO compares the Trust to other Trusts in specific areas, showing an effective use of benchmarking. The quality of BDO’s audit work is assessed by Financial Reporting Council (FRC) on an annual basis. The last report issued by FRC was in June 2019 and there were no issues highlighted in the report; the results were the same as that in the previous year. 2.3. Audit Fees

The Trust carried out a competitive External Audit tender exercise and BDO were successfully re-appointed as appointed as external auditor for 3 years from 2017/18, with a further 1 year extension awarded for 2020/21. The fees have remained the same throughout the contract.


3

For the 2019/20 financial year the summary of fees excluding VAT is as follows:

£’000

Statutory audit fee 45

Quality Report 0

Total 45

The fees are the same as those charged in 2018/19 and are in line with the fees proposed during the tender exercise. Note that no work was carried out in 2019/20 in relation to the Quality Report.

3. Recommendation The Council of Governors is asked to consider the feedback from the Audit Committee on the performance of the Trust’s External Auditors. This should provide sufficient assurance to the Council of Governors that BDO has provided a quality, timely and cost effective external audit service. The Audit Committee recommends that BDO should remain in appointment as the Trust’s External Auditors. The current contract with BDO expires on 31 March 2021, however the Audit Committee recommends that a direct award contract is given for 1 further year (covering 2021/22). Given that there are other, more pressing issues that the Trust is currently facing, the Committee considered it appropriate to defer the tender exercise for 1 year. NHS Improvement recommends that a re-tender exercise is undertaken at least every 5 years; the previous tender was undertaken 4 years ago and therefore this falls within the guidelines set. A re-tendering exercise for the external audit service will commence in July 2021 for the 2022/23 financial year.


24. Dates for meetings for 2020:Tuesday 11 AugustTuesday 22 September - Annualmembers meeting (plan to hold usingMicrosoft Teams)Wednesday 11 NovemberFor ReferencePresented by Sheila Childerhouse


25. Reflections on meetingTo consider whether the right balance hasbeen achieved in terms of informationreceived and questions for assurance andthe Trust’s values and behavioursobservedFor DiscussionPresented by Sheila Childerhouse


Documents

Council of Governors Meeting 11 August · Council of Governors Meeting There will be a meeting of the COUNCIL OF GOVERNORS of West Suffolk NHS Foundation Trust on Tuesday, 11 August